Out-of-Pocket Costs and Prescription Filling Behavior of Commercially Insured Individuals With Chronic Obstructive Pulmonary Disease

Insurance plans in the US incentivize patients to make cost-effective health care choices by incorporating cost sharing into their benefit designs.¹ These costs may contribute to patients abandoning or disrupting medically necessary treatment. With a focus on chronic obstructive pulmonary disease (COPD), we evaluated how out-of-pocket (OOP) costs are associated with prescription filling behavior among commercially insured patients.

This cohort study used IQVIA Longitudinal Access and Adjudication Data^2-4 for claims limited to patients filling COPD prescriptions between July 2017 and December 2019 through commercial insurance. Patient benefit design assignments were based on the highest cost-benefit design observed for all filled claims for that patient (COPD and non-COPD) in a calendar year, exclusive of any supplementary payment (eg, manufacturer copayment cards). Deductible claims were defined as costing patients more than 50% of total reimbursement and more than $250 per claim or more than $500. Coinsurance claims were defined as costing $75 to $250 with the patient paying 5% to 25% of costs, or the patient paid a defined percentage up to 50% of costs, or 25% to 50% of total cost as well as more than $75. All other claims in which the patient paid less than $75 were classified as copay. This study is a secondary analysis of deidentified claims data; thus, institutional review board approval was not sought. This study followed the STROBE reporting guidelines.

Branded COPD product OOP costs after any secondary support were used to analyze patient behavior in conjunction with benefit design. Abandonment was the observed rate of patients who did not fill their initial prescription within 30 days of approval. Treatment disruption was defined as a failure to refill a prescription within 30 days of the end of the previous fill. After patients abandoned treatment, their subsequent behavior was used to identify when they switched to a different treatment and how patient costs differed after switching. We set the 2-sided significance threshold at 5%. The statistical analysis was conducted using R, version 4.1.3 (R Foundation). Additional detail is available in the eMethods in the Supplement.

Of the 550 712 patients who filled branded COPD prescriptions, copay was the most prevalent benefit design (72.9%), followed by deductible (15.3%) and coinsurance (11.9%) (Table). Patients with deductibles faced average monthly OOP costs for COPD medications of $97, more than double that of coinsurance ($46) or copay ($31). Abandonment was highest among patients with a deductible (17.7%; 95% CI, 17.5%-18.0%) compared with coinsurance (11.9%; 95% CI, 11.7%-12.2%) and copay (10.1%; 95% CI, 10.0%-10.2%). At 1 year after the initial fill, the percentage of patients remaining on their initial therapy was lower for deductible (40.7%; 95% CI, 40.3%-41.0%) and coinsurance (44.7%; 95% CI, 44.3%-45.0%) relative to copay (47.7%; 95% CI, 475%-47.8%). Among patients who abandoned treatment, 39% did not fill any COPD prescriptions.

Of the 61% of patients who filled a subsequent branded or generic COPD prescription, 48% filled a prescription that resulted in lower OOP costs, 40% filled one that resulted in no change in OOP cost, and 12% were exposed to higher costs (Figure).

This analysis adds to evidence suggesting that exposure to high patient cost sharing influences the use of prescribed medicines.^5,6 In high-deductible plans, patients had the highest OOP costs and abandoned and discontinued therapy at greater rates relative to other benefit designs. Although utility exists in ensuring that patients use the most clinically appropriate and cost-effective options, these findings illustrate how cost can intervene in clinical decision-making. Drug coverage benefit designs must account for unintended clinical implications of placing cost responsibilities on patients.

Limitations of this study are common to retrospective database analyses, including data set capture, patient selection, and methodological considerations. This study is limited to commercially insured patients who filled prescriptions, and generalizability is limited to this population. Furthermore, socioeconomic factors, demographic factors, and health status, which play a critical role in drug cost affordability, were not included in this analysis and warrant further evaluation.

Accepted for Publication: March 31, 2022.

Published: May 27, 2022. doi:10.1001/jamahealthforum.2022.1167

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2022 Patel B et al. JAMA Health Forum.

Corresponding Author: Scott Howell, MD, MBA, Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936-1080 (scott.howell@novartis.com).

Author Contributions: Dr Mayne had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Patel, Mayne, Patri, Yin.

Drafting of the manuscript: Patel, Mayne, Vandigo, Yin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mayne, Patri.

Administrative, technical, or material support: Mayne, Patri, Vandigo.

Supervision: Patel, Yin, Bratti, Howell.

Conflict of Interest Disclosures: Dr Patel reported receiving personal fees from Novartis Pharmaceuticals Corporation during the conduct of the study. Dr Mayne reported receiving personal fees from Novartis Pharmaceuticals Corporation during the conduct of the study. Mr Patri reported receiving personal fees from Novartis Pharmaceuticals Corporation during the conduct of the study. Dr Vandigo reported being previously employed by Pharmaceutical Research and Manufacturers of America outside the submitted work.

Funding/Support: This study was funded by Novartis Pharmaceuticals Corporation.

Role of the Funder/Sponsor: Novartis Pharmaceuticals Corporation made the following contributions to the study: design and conduct of the study; analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The funder had no role in the collection and management of the data.