The influence of targeted education on medication persistence and generic substitution among consumer-directed health care enrollees

In 2008, approximately 8 percent (∼5.5 million) of individuals with commercial insurance were enrolled in consumer-directed health plans (CDHPs) (Claxton et al. 2008). These “high-deductible” health insurance plans encourage contributions by the employer and/or employee into tax-favorable accounts. These accounts are then used for health care–related expenses and, unlike medical savings accounts, unused funds in 1 year can be rolled over for future health care expenditures. Once the account is exhausted, the employee must pay any health expenditures out of pocket until an annual deductible is met. Upon satisfying the annual deductible, standard health coverage with copays and/or coinsurance becomes available. The CDHP insurance model relies on member involvement in health care utilization/cost decisions to manage health care expenditures (Buntin et al. 2006). Concerns have been raised that CDHPs may discourage patients from obtaining essential medical care and/or chronic medications in order to avoid out-of-pocket expenditures (Buntin et al. 2006; Ross 2006; Wilensky 2006; Hibbard, Greene, and Tusler 2008;). The evidence to date has been mixed. Parente, Feldman, and Christianson (2004) compared pharmacy and medical claims between enrollees in a CDHP (the majority with individual and family deductibles of U.S.$1,500 and U.S.$3,000, respectively), health maintenance organization (HMO), and preferred provider organization (PPO) health plans. One year after introduction of the CDHP, enrollees in the CDHP had higher adjusted mean rates of prescriptions filled and physician office visits compared with PPO but lower rates compared with HMO enrollees. On the other hand, a retrospective analysis of medical and pharmacy claims data reported a reduction in total medical office visits in the first year for enrollees of a “high-deductible” CDHP (annual individual deductible U.S.$1,500) compared with enrollees of a PPO health plan (Hibbard, Greene, and Tusler 2008). This decline occurred indiscriminately for both low- and high-priority medical office visits. Conversely, emergency department visits declined after enrollment into a high-deductible health plan (annual deductibles ranging from U.S.$500 to U.S.$2,000 for individual and U.S.$1,000 to U.S.$4,000 for families) as compared with enrollees of traditional HMO plans (Wharam et al. 2007). While there was no difference in the initial emergency visit, reduction in subsequent low-severity emergency visits occurred after enrollment into a high-deductible health plan. A retrospective analysis of employees and their dependents enrolled in a high-deductible CDHP (annual family deductible U.S.$3,000 with an employer-funded account of U.S.$1,500) reported that compared with enrollees with a PPO health plan, the CDHP enrollees were more likely to discontinue antihypertensive and lipid-lowering pharmacotherapy after implementation of the CDHP (Greene et al. 2008a). Furthermore, no difference in adherence was observed by plan type among employees who continued with their chronic medication therapy or no change in generic utilization, suggesting that additional resources are needed to encourage CDHP enrollees to make beneficial health care decisions. Navigating the CDHP insurance model for the patient involves multifaceted health care decision making while weighing personal expenditures (Goodman 2004; Greene et al. 2008b;). In lieu of the complexity of this decision making, educational programs may assist CDHP enrollees in becoming more informed health care consumers and decision makers. While patient education programs have been demonstrated to influence medication use (Cormack et al. 1994; Grace et al. 2002; Delate and Henderson 2005; Meissner et al. 2006; Tran and Billups 2008;), no information is available on the effect of enrollee education programs in CDHPs. The purpose of this study was to assess the impact of a multifaceted educational intervention on medication decision making by comparing the rates of chronic medication persistence and lower-cost medication substitution between CDHP enrollees without an educational outreach and CDHP enrollees with the medication educational outreach in a single national employer.