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Over one-third of beneficiaries received at least one low-value service, resulting in excess spending and in potential patient harm (e.g., perforation, bleeding, or infection from unnecessary colorectal cancer screening). At the claim-line-level, the three services representing the most spending were the following: opioids for acute low back pain ($188 million, 26.0%), concurrent use of two or more antipsychotic medications ($94 million, 13.0%), and unnecessary colorectal cancer screening ($79 million, 11.0%) - comprising half of wasteful spending (50%). Low-value health care services offer patients little to no clinical benefit, increase spending, and may cause patient harm. [Extracted from the article]

Introduction: Opioid use is prevalent among patients with autoimmune conditions, despite not being a recommended treatment. Tumor necrosis factor inhibitor (anti-TNF) therapy is an effective treatment for these autoimmune conditions, and patient support programs (PSPs) have been developed to help patients manage their prescribed treatments. This study was conducted to evaluate the impact of PSPs on anti-TNF adherence and opioid use using data on adalimumab (ADA), an anti-TNF. Methods: The study used insurance claims data linked to ADA PSP data on patients who initiated ADA after 01/2015, were commercially insured, and had data coverage for 1 year before and after (i.e., during the follow-up period) ADA initiation. Patients with opioid use in the 3 months before ADA initiation were excluded. PSP patients enrolled in the PSP within 30 days of ADA initiation and had 2+ PSP nurse ambassador interactions; non-PSP patients had no PSP engagement. ADA adherence [proportion of days covered (PDC), persistence], opioid initiation, 2+ opioid fills, and opioid supply during follow-up were compared between cohorts using regression models that controlled for patient characteristics. Results: Results were obtained for 1952 PSP and 728 non-PSP patients. PSP patients demonstrated better adherence to ADA than non-PSP patients, including higher PDC and persistence (all p < 0.001). PSP patients were 13% less likely to initiate opioids and 26% less likely to have at least 2 fills than non-PSP patients, and they had fewer days of opioid supply (all p < 0.01). Conclusions: This study supports the benefit of PSPs and suggests that the ADA PSP is associated with improved adherence and potentially lower opioid use. [ABSTRACT FROM AUTHOR]

Abstract Background Diabetes affects over 20 million Americans, resulting in substantial morbidity, mortality, and costs. While medications are the cornerstone of secondary prevention, many evidence-based therapies are underutilized, and patients often cite out-of-pocket costs as the reason. Value-based insurance design (VBID) is a 'clinically sensitive' refinement to benefit design which links patient cost-sharing to therapy value; the more clinically beneficial (and valuable) a therapy is for a patient, the lower that patient's cost-sharing should be. We describe the design and implementation of MHealthy: Focus on Diabetes (FOD), a prospective, controlled trial of targeted co-payment reductions for high value, underutilized therapies for individuals with diabetes. Methods The FOD trial includes 2,507 employees and dependents with diabetes insured by one large employer. Approximately 81% are enrolled in a single independent-practice association model health maintenance organization. The control group includes 8,637 patients with diabetes covered by other employers and enrolled in the same managed care organization. Both groups received written materials about the importance of adherence to secondary prevention therapies, while only the intervention group received targeted co-payment reductions for glycemic agents, antihypertensives, lipid-lowering agents, antidepressants, and diabetic eye exams. Primary outcomes include medication uptake and adherence. Secondary outcomes include health care utilization and expenditures. An interrupted time series, control group design will allow rigorous assessment of the intervention's impact, while controlling for unrelated temporal trends. Individual patient-level baseline data are presented. Discussion To our knowledge, this is the first prospective controlled trial of co-payment reductions targeted to high-value services for high-risk patients. It will provide important information on feasibility of implementation and effectiveness of VBID in a real-world setting. This program has the potential for broad dissemination to other employers and insurers wishing to improve the value of their health care spending.