The industry is buzzing about value-based benefit design. In a value-based approach, employers invest strategically in benefits and health management practices that
improve the health of employees, especially those at high risk for chronic illness or
costly major medical events. The return they aim to achieve over time is lower overall
health care costs and increased employee productivity.
Although the marketplace is working in earnest to implement a range of value-based
approaches to the drug benefit, PBMI research indicates it is still early in the adoption
cycle. The three predominant emerging applications in drug benefit plans are:
- Reduced or waived copayments for maintenance medications,
- Copayment relief in combination with disease management, and
- Enterprise-wide efforts to assess risk, encourage wellness, and provide disease-specific
resources when needed – often with financial incentives for employee
Early adopters of value-based benefit design have increased medication adherence
and improved health status of covered populations, but it’s too soon for much hard data
on cost savings. As health care payers consider value-based design, it is important
to consider these implications for the drug benefit program.
- Plan sponsor drug costs are likely to increase initially due to higher utilization and
decreased member cost share. Utilization inevitably goes up as a result of improved
medication adherence and newly identified high risk members who need to begin
- Aggressive utilization management is necessary to maximize the use of generics
and other low cost alternatives as an offset to the increased expense of copayment
relief and improved adherence.
- Integration of pharmacy, medical, and lab data is essential to identify the chronic
health conditions most costly to the organization and stratify members by risk so
that value-based efforts can be prioritized as shown in Figure 12. Integrated data
also are key to measuring clinical and economic return on investment (ROI).
- Drug benefit design and health management programs should be integrated.
Copayment relief alone may not be enough to change noncompliant behavior and
unhealthy lifestyle habits. Financial incentives combined with member accountability
for participation in health management programs and changes in behavior have
proven successful in increasing medication adherence and improving health status.
- Studies show it’s possible to realize favorable clinical outcomes in the first year of a
value-based drug benefit initiative. It takes longer to realize economic ROI – medical
and drug cost savings, lower absenteeism, and increased productivity traced to
improved medication management and a healthier workforce.