Pitfalls in Linking Cost Sharing to Value

IN RESPONSE:

We thank Dr. Polsky for highlighting several substantive issues. Reference pricing (that is, paying the price of only the cheapest drug within a class of similarly effective drugs) is only 1 among many ways to link cost sharing to value, and it also only concerns drugs within a particular class. We endorse an approach that is sufficiently flexible to address a broad range of drug and nondrug clinical alternatives.

We recognize that cost-sharing decisions may be plagued by accusations of caprice and conflict of interest, and these same concerns motivated our work. We have proposed a more objective method of making cost-sharing decisions that may ultimately diffuse some of this criticism. A new national center for comparative clinical effectiveness research may further enhance these efforts.

Evidence limitations are always an important concern in medical decision making. However, endorsing a particular decision-making framework may lead to greater efforts to gather relevant evidence. New approaches may make the use of existing evidence more transparent (1). “Abundant, head-to-head studies” may not always be necessary, particularly if additional data would be unlikely to change a decision (2).

Waiving cost-sharing for HEDIS measures is a sensible idea that is complementary rather than alternative to our approach. However, only some high-value interventions may be encompassed by HEDIS measures. Conversely, some HEDIS measures may lack evidence of cost-effectiveness. We advocate using a more conceptually robust and generalizable method.

We agree with Dr. Polsky that pharmaceutical copayments should, in general, not be considered penalties. However, when there is overwhelming evidence of cost-effectiveness, copayments may act as such. Indeed, in the rare circumstances when therapies are cost-saving (for example, β-blockers after myocardial infarction), a logical extension of the cost-sharing ethos would be to share that cost savings with the patient (that is, to provide a small inducement for adherence).

Finally, Dr. Polsky raises 2 common concerns for payers: Can value-sensitive health plans be implemented in practice, and will they save money? These questions have different answers. Pitney Bowes, University of Michigan, Marriott, and Mohawk Industries are just a few examples of employers that have successfully adopted value-based copayment programs, so they are definitely feasible. However, it is not appropriate to expect that these programs will always save money. We must remember that the primary return on a health care spending investment is good health.