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OBJECTIVES To determine whether elimination of co-pays for prescription drugs affects medication adherence and total health care spending. STUDY DESIGN Retrospective comparative study. METHODS We conducted a difference-in-differences comparison in the year before and after expansion of a Zero Dollar Co-pay (ZDC) prescription drug benefit in commercially insured Louisiana residents. Blue Cross and Blue Shield of Louisiana members with continuous disease management program enrollment were analyzed, of whom 6463 were enrolled in the ZDC program and 1821 were controls who were ineligible because their employers did not opt in. RESULTS After ZDC expansion, medication adherence fell in the control group and rose in the ZDC group, with a relative increase of 2.1 percentage points (P = .002). Medical spending fell by $71 per member per month (PMPM) (P = .027) in the ZDC group relative to controls. Overall, there was no significant increase in the cost of drugs between treatment and controls. However, when drugs were further categorized, there was a significant increase of $8 PMPM for generic drugs and no significant difference for brand name drugs. Comparisons of medication adherence rates by household income showed the largest relative increase post ZDC expansion among low-income members. CONCLUSIONS Elimination of co-pays for drugs indicated to treat chronic illnesses was associated with increases in medication adherence and reductions in overall spending of $63. Benefit designs that eliminate co-pays for patients with chronic illnesses may improve adherence and reduce the total cost of care.

Objectives To determine whether a program that eliminated pharmacy co-pays, the Blue Cross Blue Shield of Louisiana (BCBSLA) Zero Dollar Co-pay (ZDC) program, decreased health care spending. Previous studies have found that value-based insurance designs like the ZDC program have little or no impact on total health care spending. ZDC included an expansive set of medications related to 4 chronic diseases rather than a limited set of medications for 1 or 2 chronic diseases. Additionally, ZDC focused on the most at-risk patients. Study design ZDC began in 2014 and enrolled patients over time based on (1) when a patient answered a call from a nurse care manager and (2) when a patient or their employer changed the benefit structure to meet the program criteria. During 2015 and 2016, 265 patients with at least 1 chronic condition (asthma, diabetes, hypertension, mental illness) enrolled in ZDC. Methods Observational study using within-patient variation and variation in patient enrollment month to identify the impact of the ZDC program on health spending measures. We used 100% BCBSLA claims data from January 2015 to June 2018. Monthly level event studies were used to test for differential spending patterns prior to ZDC enrollment. Results We found that total spending decreased by $205.9 (P = .049) per member per month, or approximately 18%. We saw a decrease in medical spending ($195.0; P = .023) but did not detect a change in pharmacy spending ($7.59; P = .752). We found no evidence of changes in spending patterns prior to ZDC enrollment. Conclusions The ZDC program provides evidence that value-based insurance designs that incorporate a comprehensive set of medications and focus on populations with chronic disease can reduce spending.

Background We present a knee injection and aspiration course, with simulated rheumatology clinical scenarios targeting core medical trainees. Simulation should be a core part of the curriculum, providing a safe learning environment, as hands on rheumatology exposure is often limited. Objectives 1. To review and compare two different rheumatology practical teaching courses. 2. To highlight important rheumatology cases presenting on the acute medical take, and achieve the requirements on the core medical training curriculum.1 3. With training emphasis on service provision, to provide organised targeted teaching.2 Methods Eight core medical trainees were recruited to a knee aspiration and injection course at a cardiothoracic specialist centre (no on-site rheumatology). There was a pre-course assessment, pre-course handout, followed by a practical demonstration on a knee manikin3 by a competent teacher. Each trainee underwent assessement: Directly Observed Procedures – DOPs assessment. Pre- and post- course surveys evaluated confidence. Six months later, a second cohort of eight trainees were recruited, and the session was delivered by a rheumatology registrar. There was a brief lecture, followed by a demonstration. Trainees also underwent one-to-one assessment with SimMan® (scenarios: prosthetic joint septic arthritis and haemoptysis secondary to TB reactivation following anti-TNF treatment). Results –Trainee experience prior to teaching: Cohort 1: 12.5% no experience. 37.5% seen but not attempted. 50% performed with supervision only. Cohort 2: 25% no experience. 37.5% seen but not attempted. 37.5% performed with supervision only. –Confidence pre- and post teaching: Cohort 1: Initially only 40% had confidence in aspirating a knee joint. Increased to 80%. Cohort 2: Initially 34% had confidence in aspirating a knee joint. Increased to 85%. –100% trainees identified correct anatomical landmarks, proving that clinicians possess the knowledge but are limited by experience and resources. –Outcomes were suprisingly largely unchanged despite involving a rheumatology registrar. Conclusions - Opportunities to gain practical experience are infrequent. This affects trainees rotating through multiple training centres. Trainee confidence is increased through simulation, however simple organised teaching sessions are currently not readily available. –Limitations: Small cohorts, inconsistent outcomes due to two sessionsbeing delivered by different people. It is dfficult to directly compare the cohorts, as cohort 2 included SimMan®. However confidence was slightly increased with this, showing that simulation is an effective learning tool. –This program may be targeted at rheumatology specialist trainees too. References Joint Royal Colleges of Physicians Training Board. Specialty training curriculum for core medical training. http://www.jrcptb.org.uk/sites/default/files/FINAL%202009%20CMT%20Curriculum%20%28AMENDMENTS%20Aug%202013%29.pdf (accessed March 2015). Tasker, F et al. 2014. Survey of core medical trainees in the United Kingdom 2013 – inconsistencies in training experience and competing with service demands. Clinical Medicine Vol 14, No 2: 149–56 Limbs and Things UK. Knee for Aspiration Mk 2. https://www.limbsandthings.com/uk/products/knee-for-aspiration-mk-2 (accessed March 2015). Disclosure of Interest None declared