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Money Don’t Mean A Thing

Patient adherence to prescribed therapy depends on more than just upfront costs. (Volume 10, Issue 16)

Does making medications free affect a patient’s decisions to adhere to therapy for chronic conditions? In a study conducted at Kaiser Permanente, patients in a no deductible plan were moved to a deductible plan with either Value Based Insurance Design (VBID) or no VBID.  As part of the VBID plan, prescriptions that were considered “high-value” were free – including those for diabetes, hypertension, and high cholesterol.

Copyright: Health Affairs

Patients that were moved from the no deductible plan to the no VBID plan demonstrated decreased adherence by 2 percentage points, down from 76% to 74%. Patients that moved to the VBID plan maintained their adherence at 74%.

Among non-adherent patients and those with fewer than 9 medications, adherence was higher by 5.2% and 3.4%, respectively, comparing VBID to no VBID (p < 0.05).

The study would have better evaluated the true efficacy of VBID if employees had not moved from a no deductible plan to one with a deductible. These employer decisions potentially confound the applicability of this analysis.

Although the results are statistically significant, the benefit of VBID and free “high-value” medications are marginal. Arguably, free medications helped improve the results of non-adherent patients by 5%.  One could also state VBID prevented the overall adherence from dropping 2 percentage points after adding a deductible to the employer health plan. However, I profess that cost is not the main factor for nonadherence because of the modest differences faced by these patients.

Why do people not take their medication when it is free? Potential factors include health literacy, understanding regarding chronic conditions, education, transportation, and other social determinants of health. Could it be that not paying for medications decreases the perceived value of prescription drugs? Whose responsibility is it to ensure medication adherence – the doctor, the pharmacist, the insurance company, or the patient? The authors suggest to “engage and educate” but I believe there should better ways to design a system that aligns incentives for the patient. Whether to believe in VBID or not, we have much work to do in order to improve medication adherence among our patients.

This Policy Prescriptions® review is written by Catherine Wu as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine. Ms. Wu is a first year medical student.


Enrollment in high-deductible health plans is increasing out-of-pocket spending. But innovative plans that pair deductibles with value-based insurance designs can help preserve low-cost access to high-value treatments for patients by aligning coverage with clinical value. Among adults in high-deductible health plans who were prescribed medications for chronic conditions, we examined what impact a value-based pharmacy benefit that offered free chronic disease medications had on medication adherence. Overall, we found that the value-based plan offset reductions in medication adherence associated with switching to a deductible plan. The value-based plan appeared particularly beneficial for patients who started with low levels of medication adherence. Patients with additional clinical complexity or vulnerable populations living in neighborhoods with lower socioeconomic status, however, did not show adherence improvements and might not be taking advantage of value-based insurance design provisions. Additional efforts may be needed to educate patients about their nuanced benefit plans to help overcome initial confusion about these complex plans.

PMID: 28264954

Reed, ME, et al. Health Affairs.  2017; 36 (3): 516-523.