Heart Disease and Stroke Prevention: Reducing Out-of-Pocket Costs for Cardiovascular Disease Preventive Services for Patients with High Blood Pressure and High Cholesterol
Summary of CPSTF Finding
There was not enough evidence to support ROPC for behavioral counseling or behavioral support services independent of reducing patient costs for medications.
Intervention
- Medications
- Behavioral counseling (e.g., nutrition counseling)
- Behavioral support (e.g., community-based weight management programs, gym membership)
Costs for these services can be reduced by providing new or expanded treatment coverage and lowering or eliminating patient out-of-pocket expenses (e.g., copayments, coinsurances, deductibles).
ROPC is coordinated through the healthcare system and preventive services may be delivered in clinical or non-clinical settings (e.g., worksite, community). ROPC can be implemented alone or in combination with additional interventions to enhance patient-provider interaction (e.g., team-based care, medication counseling, patient education). Program and policy changes may be communicated to patients and providers using targeted messages to increase awareness and use of covered services.
CPSTF Finding and Rationale Statement
Promotional Materials
- New Publication: Reducing Medication Costs Improves Blood Pressure and Cholesterol
Developed by The Community Guide in collaboration with CDC’s Division for Heart Disease and Stroke Prevention
About The Systematic Review
The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.
Summary of Results
- Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.
- Included studies were stratified based on suitability of study designs, as defined by the CPSTF (Briss et al., 2000).
- Twelve studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (3 studies), other designs that have a concurrent comparison group (6 studies), retrospective cohort (2 studies), post only with concurrent comparison (1).
- Six studies used a design considered to be least suitable: before-after without a comparison group.
Medication Adherence
- Patients’ adherence to blood pressure and cholesterol-lowering medications
- Greatest/moderate suitability studies: median increase of 3.0 percentage points (6 studies, 15 study arms).
- Proportion of patients achieving 80% adherence
- Greatest/moderate suitability studies: increase of 5.1 percentage points (1 study)
Blood Pressure
- Patients’ systolic blood pressure
- Greatest/moderate suitability studies: median decrease of 5.9 mmHg (4 studies)
- Least suitability studies: median decrease of 8.7 mmHg (6 studies)
- Patients’ diastolic blood pressure
- Greatest/moderate suitability studies: median decrease of 3.8 mmHg (4 studies)
- Least suitability studies: median decrease of 4.5 mmHg (6 studies)
- Proportion of patients achieving blood pressure goal (<140 mmHg/90 mmHg; 130/80 mmHg for people with diabetes)
- Greatest/moderate: median increase of 6.0 percentage points (3 studies)
- Least suitability studies: median increase of 30.1 percentage points (4 studies)
Cholesterol
- Patients’ total cholesterol
- Greatest/moderate suitability design: decrease of 15.0 mg/dL (1 study)
- Least suitability design: decrease of 25.0 mg/dL (1 study)
- Patients’ low-density lipoprotein (LDL)
- Greatest suitability design: median decrease of 14 mg/dL (3 studies)
- Least suitability of design: median decrease of 14 mg.dL (3 studies, 6 study arms)
- Patients LDL level at goal (<100mg/dL for most patients)
- Greatest suitability studies: increases of 13.0 and 24.0 percentage points (2 studies)
- Least suitability studies: increase of 10 percentage points (1 study)
- Patients’ triglycerides
- Greatest suitability studies: decreases of 13.0 and 9.8 mg/dL (2 studies)
- Lest suitability studies: decreases of 38.4 and 25.0 mg/dL (2 studies)
Summary of Economic Evidence
The economic review included nine studies. Monetary values are reported in 2014 U.S. dollars.
- No studies reported cost-effectiveness results.
- The median intervention cost per person per year was $172 (9 studies).
- Higher estimates included blood pressure-lowering and diabetes medications.
- Healthcare cost decreased by a median of $127 (7 studies)
- Estimates from all but two studies were the result of ROPC combined with other interventions.
An overall economic conclusion cannot be reached because the net benefit evidence is small and inconsistent and no studies reported cost-effectiveness.
Applicability
- Adults (18-64 years old)
- Women and men
- Hispanic, white, and African-American patients
- Low-income patients
Evidence Gaps
- Does ROPC for behavioral counseling or behavioral support interventions independent of ROPC for medications improve health outcomes?
- How does the dollar amount saved by patients affect intervention effectiveness? What is the effectiveness of ROPC by total medication cost, proportional cost-reduction, patient income, or drug patent type?
- When the cost for generic medications is eliminated and the cost for brand name medications is reduced, are patients more or less likely to choose generic options?
- What clinical outcomes are associated with policies that reduce out-of-pocket costs for an entire patient population? How is medication adherence affected by multicomponent programs that include ROPC?
- What are the most effective strategies to promote covered benefits to patients and providers?
- What costs are associated with each component of a combined ROPC intervention?
Study Characteristics
- Included studies came from the United States (15 studies), Israel (1 study), Italy (1 study), and Australia (1 study).
- Seven of the studies used Value-based Insurance Design plans, and three used pharmaceutical medication assistance programs (PMAP) programs to procure medications for low-income patients.
- Most studies reported implementing ROPC for medications with one or more health care intervention components, such as medication counseling; seven studies used a team-based care approach combined with medication counseling.
- Study populations primarily included working-age adults (median age of 55 years).
- Populations included diverse racial and ethnic groups, which were predominantly white in three studies; African American in 2 studies, and Hispanic in one study.
- Patients in 12 studies were fully insured. Patients in the remaining six studies were mostly uninsured or underinsured.
Publications
Analytic Framework
Effectiveness Review
When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.
Summary Evidence Table
Included Studies
Effectiveness Review
Alderman MH, Melcher LA. A company-instituted program to improve blood pressure control in primary care. Isr J Med Sci 1981;17(2-3):122-8.
Applegate BW, Ames SC, Mehan DJ, Jr., McKnight GT, Jones GN, Brantley PJ. Maximizing medication adherence in low-income hypertensives: a pilot study. J La State Med Soc 2000;152(7):349-56.
Atella V, Peracchi F, Depalo D, Rossetti C. Drug compliance, co-payment and health outcomes: Evidence from a panel of Italian patients. Health Economics 2006;15(9):875-92.
Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc 2008;48(1):23-31.
Chernew ME, Shah MR, Wegh A, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Affairs 2008;27(1):103-12.
Choudry NK, Fischer MA, Smith BF, Brill G, Girdish C, Matlin OS, et al. Five features of value-based insurance design plans were associated with higher rates of medication adherence. Health Aff 2014;33(3):493-501. Available at URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=Pubmed&list_uids=24522551&dopt=Abstract
Elhayany A, Vinker S. Addressing healthcare inequities in Israel by eliminating prescription drug copayments. Am J Manag Care 2011;17(7):e255-9.
Farley JF, Wansink D, Lindquist JH, Parker JC, Maciejewski ML. Medication adherence changes following value-based insurance design. Am J Manag Care 2012;18(5):265-74.
Gibson TB, Wang S, Kelly E, et al. A value-based insurance design program at a large company boosted medication adherence for employees with chronic illnesses. Health Affairs 2011;30(1):109-17.
Haskell WL, Berra K, Arias E, et al. Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients. Am J Cardiology 2006;98(11):1472-9.
Hill MN, Han H-R, Dennison CR, et al. Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. Am J Hypertens 2003;16(11):906-13.
Keeler EB, Brook RH, Goldberg GA, Kamberg CJ, Newhouse JP. How free care reduced hypertension in the health insurance experiment. JAMA 1985;254(14): 1926-31.
Knott RJ, Petrie DJ, Heeley EL, Chalmers JP, Clarke PM. The effects of reduced copayments on discontinuation and adherence failure to statin medication in Australia. Health Policy 2015;119(5): 620-7.
Maciejewski ML, Wansink D, Lindquist JH, Parker JC, Farley JF. Value-based insurance design program in North Carolina increased medication adherence but was not cost neutral. Health Aff 2014;33(2): 300-8.
Musich S, Wang S, Hawkins K. The impact of a value-based insurance design plus health coaching on medication adherence and medical spending. Popul Health Manag 2015;18(3): 151-8.
Sauvageot J, Kirkpatrick MAF, Spray JW. Pharmacist-implemented pharmaceutical manufacturers’ assistance programs: effects on health outcomes for seniors. Consultant Pharmacist 2008;23(10):809-12.
Trompeter JM, Havrda DE. Impact of obtaining medications from pharmaceutical company assistance programs on therapeutic goals. Ann Pharm 2009;43(3):469-77.
Wertz D, Hou L, DeVries A, Dupclay L Jr, McGowan F, Malinowski B, Cziraky MJ. Clinical and economic outcomes of the Cincinnati Pharmacy Coaching Program for Diabetes and Hypertension. Manag Care 2012;21(3):44-54.
Additional References Linked to Included Effectiveness Studies
Brook RH, Ware JE, Jr., Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. NEJM 1983;309(23):1426-34.
Maciejewski ML, Farley JF, Parker J, Wansink D. Copayment reductions generate greater medication adherence in targeted patients. Health Affairs 2010;29(11):2002-8.
Kelly EJ et al. Value-based benefit design and healthcare utilization in asthma, hypertension, and diabetes. Am J Pharm Benefits 2009;1(4):217-21.
Economic Review
Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc (2003) 2008;48(1):23 31.
Chernew ME, Juster IA, Shah M, Wegh A, Rosenberg S, Rosen AB, et al. Evidence that value-based insurance can be effective. Health Aff 2010:29(3):530-6.
Choudhry NK, Fischer MA, Avorn JL, Lee JL, Schneeweiss S, Solomon DH, et al. The impact of reducing cardiovascular medication copayments on health spending and resource utilization. J Am Coll Cardiol 2012;60(18):1817 24.
Elhayany A, Vinker S. Addressing healthcare inequities in Israel by eliminating prescription drug copayments. Am J Manag Care 2011;17(7):e255 9.
Gibson TB, Wang S, Kelly E, Brown C, Turner C, Frech-Tamas F, et al. A value-based insurance design program at a large company boosted medication adherence for employees with chronic illnesses. Health Aff 2011;30(1):109 17.
Kelly EJ, Turner CD, Frech-Tamas FH, Doyle JJ, Mauceri EG. Value-based benefit design and health care utilization in asthma, hypertension, and diabetes. Am J Pharm Benefits 2009;1(4):217 21.
Maciejewski ML, Wansink D, Lindquist JH, Parker JC, Farley JF. Value-based insurance design program in North Carolina increased medication adherence but was not cost neutral. Health Aff 2014;33(2):300 8.
Musich S, Wang S, Hawkins K. The impact of a value-based insurance design plus health coaching on medication adherence and medical spending. Popul Health Manag 2015;18(3):151-8.
Wertz D, Hou L, DeVries A, Dupclay L Jr, McGowan F, Malinowski B, et al. Clinical and economic outcomes of the Cincinnati Pharmacy Coaching Program for diabetes and hypertension. Manag Care 2012;21(3):44 54.
Additional Materials
- Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effective Health Care System Interventions and Community-Clinical Links
Developed by CDC’s Division for Heart Disease and Stroke Prevention
Search Strategies
Studies published in English from 1980 through July 2015, limited to countries with high-income economies as defined by the World Bank were searched and screened for inclusion.
Database: PubMed (NLM); 765 Results
“high blood pressure” OR “high cholesterol” OR “high level lipid” OR “high lipid level” or “high lipid levels” OR “high level lipids” OR hyperlipidemias[MeSH Terms] OR “blood fat” or “blood fats” OR “blood lipid” or “blood lipids” OR “lower blood pressure” “lowered blood pressure” or “lower cholesterol” or “lowered cholesterol” OR “lowering cholesterol” OR “lower lipid” or “lower lipids” or “lowered lipid” or “lowered lipids” or “lowering lipid” or “lowering lipids” OR “Antihypertensive Agents”[Mesh] OR “Anticholesteremic Agents”[Mesh]
AND
“amount paid” OR “amounts paid” OR “cheap” OR “cheaper” OR “cheapest” OR “copay” OR “co-pay” OR “copayer” OR “copayers” OR “copaying” OR “co-payment” OR “co-payments” OR copayment* OR “copays” OR “copays” OR “cost assistance” OR “Cost Sharing”[Mesh] OR “cost sharing” OR coupon OR coupons OR “fee reduction” OR “fee reductions” OR Fees, Pharmaceutical[Mesh] OR “financial assistance” OR “free class” OR “free classes” OR “free clinic” OR “free clinical” or “free clinics” OR “free counseling” OR “free counselling” OR “free coverage” OR “free drug” OR “free drugs” OR “free hospital” OR “free instruction” OR “free medical” OR “free medication” OR “free medications” OR “free membership” OR “free memberships” OR “health insurance incentive” OR “health insurance incentives” OR “health plan incentive” OR “health plan incentives” OR “less cost” or “less costly” OR “Medical Assistance”[Mesh:noexp] OR “medical indigence” OR “Medical Indigency”[Mesh] Or “medication assistance program” OR “medication assistance programs” OR “medication coverage” OR “medication costs” OR “medication cost” OR “medication possession” OR “out of pocket” OR “patient satisfaction” or “pharmaceutical company assistance” OR “prescription drug burden” OR “prescription drug charges” OR “prescription drug claim” OR “prescription drug claims” OR “prescription drug copayment” OR “prescription drug copayments” OR “prescription drug cost” OR “prescription drug costs” OR “prescription drug coverage” OR “prescription drug discount” OR “prescription drug insurance” OR “prescription drug payment” OR “prescription drug payments” OR “prescription drug plan” OR “prescription drug plans” OR “prescription drug prices” OR “prescription drug pricing” OR “prescription drug reimbursement” OR “prescription drug spending” OR “prescription drug subsidies” OR “prescription drug subsidy” OR “prescription drug user fee” OR “prescription drug user fees” OR “prescription drugs/economics”[MeSH] OR “provided free” OR “reduced cost” OR “reduced costs” OR “reduced health care cost” OR “reduced health care costs” OR “reduced healthcare cost” OR “reduced healthcare costs” OR subsidies OR subsidized OR subsidizing OR subsidy OR “Uncompensated Care”[Mesh] OR “uncompensated care” OR “VA benefit” OR “VA benefits” OR “value based” OR “veterans benefit” OR “veterans benefits” OR “voucher” or “vouchers”
NOT
Africa[Mesh] OR South America[Mesh] OR Mexico[Mesh] OR Latin America[Mesh] OR India[Mesh] OR Pakistan* OR mice or Central America[Mesh] or China OR Developing Countries[MeSH] or rats
Database: MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to Present (OVID); 202 Results
1 (cholesterol adj3 goal).tw.
2 (improv* adj4 (cholesterol or lipid or lipids)).tw.
3 free-clinic*.tw.
4 medication-cost*.tw.
5 cost sharing/
6 anticholesteremic agents.rnp.
7 anticholes*.mp.
8 high-blood-pressure.tw.
9 medical indigency/
10 Health Benefit Plans, Employee/ec [Economics]
11 medically uninsured/
12 Cholesterol/bl [Blood]
13 Cholesterol, LDL/bl [Blood]
14 Cholesterol, HDL/bl [Blood]
15 Hypertension/
16 1 or 2 or 6 or 7 or 8 or 12 or 13 or 14 or 15
17 3 or 4 or 5 or 9 or 10 or 11
18 16 and 17
19 limit 18 to (English language and yer=”1980 current)
Database: ABI INFORM (PROQUEST); 195 Results
ALL (hypertension or hyperlipidemia* or “antihypertensive* or cholesterol or anticholes* or “blood fat*” or “blood lipid*” or dyslipidemia or “high blood pressure” or “high lipid*” or LDL or “lipid lowering” or “low density lipoprotein*” or “low lipid*” or “lower* lipid*” or “elevated lipid*”) or SU.EXACT(“Hypertension”) OR SU.EXACT(“Cardiovascular Disease)
AND
ALL(“reduc* cost” or “cost sharing” or “sharing cost*” or “shared cost*” or copay* or “co-pay*” or “medication assistance” or “pharmaceutical company assistance” or “medication possession” or “cost-share” or “medical indigence” or “subsidized prescription*” or “cost assistance” or “fee-reduction*” or “medication cost* reduction*” or “out-of-pocket” or “value-based” or “health insurance incentive*” or “health plan* incentive*” or benefit* or complimentary or coupon* or cover* or discount* or “financial assistance” or “financially vulnerable” or “patient satisfaction” or voucher* or free or gift or incentive* or indigen* or “low income” or uninsured or “free medication*” or “free prescription*” or “free drugs” or “assistance program*” or “reduc* fee*” or “reduc* healthcare cost*” or “reduc* health care cost*” or subsidy or subsidies or subsidized or subsidised or uncompensated or underserved or urban) OR SU.EXACT(“Out of pocket costs”) OR (ALL(Counseling) AND ALL(“reduced cost”))
Database: CINAHL (EBSCOhost); 2911 Results
Limiters – Published Date from: 19810101-20120701
Language: English
S5 S1 AND S4
S4 S2 OR S3
S3 MW(cover* OR complimentary OR free OR coupon* or discount* OR reduc* OR susidiz* OR subsidies OR subsidy OR subsidis* OR “out of pocket” OR “out-of-pocket OR copay* OR “co-pay*” OR gift* OR voucher* OR eliminat* OR “value-based” OR compensat* OR free OR incentiv* OR “cost sharing” OR “shared cost” OR “shared costs” OR “medication assistance program*” OR “pharmaceutical company assistance” OR “manufacturer* assistance” OR PMAPs OR uncompensated or indigen* OR “financially vulnerable” OR “medication possession” OR “cost assistance” or “fee reduction*” OR “reduc* fee*” OR “decreas** fee*” OR eliminat* OR “low income” OR “health benefits plan*” OR underserved OR urban)
S2 TI(cover* OR complimentary OR free OR coupon* or discount* OR reduc* OR susidiz* OR subsidies OR subsidy OR subsidis* OR “out of pocket” OR “out-of-pocket OR copay* OR “co-pay*” OR gift* OR voucher* OR eliminat* OR “value-based” OR compensat* OR free OR incentiv* OR “cost sharing” OR “shared cost” OR “shared costs” OR “medication assistance program*” OR “patient satisfaction” OR “pharmaceutical company assistance” OR “manufacturer* assistance” OR PMAPs OR uncompensated or indigen* OR “financially vulnerable” OR “medication possession” OR “cost assistance” or “fee reduction*” OR “reduc* fee*” OR “decreas** fee*” OR eliminat* OR “low income” OR “health benefits plan*” OR underserved OR urban)
S1 “high blood pressure” or hypertension or hyperlipidemia or “high cholesterol” or “blood fats” or “blood lipid” or “blood lipids” or “blood fat” or antihypertensive* or “anti-hypertensive*” or dyslipidemia or “high lipid*” or hyperlipid* or LDL or “lipid lowering” or “lower* lipid*” or “elevated lipid*” or “low lipid*” or “lower* cholesterol” or “total cholesterol” or “elevated cholesterol” or anticholester* or “cholesterol lower*”
Database: Cochrane Library; 384 Results
#1 hypertension or “high blood pressure” or antihypertensive*:ti,ab,kw (Word variations have been searched)
#2 hypercholesterolemia or hypercholesterolaemia or “high cholesterol” or hyperlipid* or “high lipid” or “lower lipid” or “lowered lipid” or “lowering lipid” “low density lipoprotein cholesterol” or “LDL” or “total cholesterol” or “lower cholesterol ” or “lowered cholesterol” or “lowering cholesterol” or anticholester* or “blood fat” or “blood fats” or “blood lipid” or “blood lipids” or “cholesterol lowering” or “cholesterol lowered” or “cholesterol level” or “cholesterol levels”.ti,ab,kw.
#3 MeSH descriptor: [Hypertension] explode all trees
#4 “out-of-pocket” or “out of pocket” or cost* or cover* or benefit* or compensate* or complimentary or “co-pay” or “co-payment” or “co-payer” or “co-payments” or “co-payers” or copay* or cost* or cover* or coverage* or “medication possession” or “patient satisfaction” or subsidis* or subsidiz* or subsidy or subsidies or uncompensated or “value-based” or voucher* or free or coupon* or indigen*.ti,ab,kw.
#5 (#1 or #2 or #3) and #4
Database: EconLit (Ebscohost) 110 Results
Search modes – Boolean/Phrase
Limiters – Published Date from: 19800101-20150701
S14 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13
S13 hyperlipid*
S12 anti-cholester*
S11 anticholester*
S10 anti-hypertensive*
S9 antihypertensive*
S8 “blood pressure”
S7 “lipid levels”
S6 “blood fat” or “blood fats.
S5 cholesterol
S4 hypercholester*
S3 hypertension
S2 “high blood pressure”
S1 “blood lipid” or “blood lipids”
Database: Embase (OVID); 5108 Results
1. (“high blood pressure” or hypertension or hyperlipidemia or “high cholesterol” or “blood fats”).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
2. (blood-lipid or blood-lipids or lipid-level or lipid-levels or cholesterol-lower* or lower*-cholesterol or lipid-lower* or lower*-lipid*).mp
3. (elevated-lipid* or blood-fat* or antihypertensive*).mp.
4. dyslipidemias.mp. or exp Hyperlipidemias/ or dyslipidemia.mp.
5. exp Antihypertensive Agents/ec [Economics] or . exp Hypolipidemic Agents/ec [Economics]
6. (“reduced healthcare cost*” or “reduced health care cost*” or “insurance incentive*” or “health plan* incentive*” or “uncompensated care” or “free medication*” or “subsidized medication*” or “medical indigen*” or “subsidized prescription*”).mp.
7. (“cost assistance” or “fee reduction*” or “reduced fee*”).mp
8. urban.ti. or (insurance-benefit* or insurance-coverage* or prescription-drug*-coverage* or prescription-drug*-benefit* or drug-coverage* or prescription-coverage* or financial-assist* or discount* or compensated or “medication possession” or “patient satisfaction”).mp.
9. (cost* or economic* or insurance or compensat*).ti. or (value-based.mp. or medication-possession-rate or medication-possession-ratio or mpr).mp.
10. high-cost*.mp.
11. prescription fees/ or fees, pharmaceutical/ or prescription fees/ or financing, personal/
12. fees, medical/ or shifting-fees.mp. or . shifting-costs.mp.
13. (out adj1 pocket).mp. or “out-of-pocket”.mp.
14. oop-cost* or decrease*-fee* or reduc*-fee* or subsidiz* or subsidy or subsidies or subsidis* or complimentary).mp.
15. (out-of-pocket or complimentary or reduc*-cost* or underserved or indigence or indigent).mp.
16. (low-cost* or lower-cost* or lowered-cost*).mp.
17. (fee-free or fees-free or less-money or lower*-fee or lower*-fees).mp.
18. (assistance-fund* or lower*-spending or spent-less or dollar* or reduc*-fee*).mp.
19. coupon*.mp.
20. (medical-coverage* or expense*-cover* or cost-cover* or drug-cover* or prescription*-cover* or medication*-cover* or compensate*-cost* or compensate*-fee*).mp.
21. (compensate*-expense* or cover*-medical or cover*-medicine* or cover*-medication* or cover*-drug* or cover*-prescription* or cost*-compensat* or expense*-compensat*).mp.
22. patient*-cost*.mp.
23. (free-healthcare or free-health-care or free-prescription* or free-medicine* or free-medication* or free-drug).mp.
24. (free-drugs or provide*-free or free-membership* or free-class* or free-counsel* or free-instruction).mp.
25. (pace or medicaid or medicare or free-coverage* or free-voucher* or free-gift* or free-insurance or government-provide* or free-medical or va-benefit*).mp.
26. (veterans-benefit* or veteran*-benefit* or veterans*-administration or program-provide* or subsidiz*).mp.
27. (subsidy or subsidies or subsidis* or out-of-pocket or oop-cost* or copay* or gift* or voucher* or value-based).mp.
28. (eliminat*-cost* or (cost* adj2 eliminat*)).mp.
29. (eliminat*-fee* or (fee* adj2 eliminat*) or eliminat*-charge*).mp.
30. (“value-based” or incentive* or “cost sharing” or “shared cost” or “shared costs” or sharing-cost* or co-pay* or value-based-insurance* or medication-assistance-program* or cost-assistance or (assist* adj2 cost*)).mp.
31. (pharmaceutical-compan*-assistance or reduced-cost* or drug-compan*-assistance or cost-compensation* or compensat*-cost* or compensat*-fee* or ((cost* or fee* or charges or amount* or pay* or paid) adj3 compensat*)).mp.
32. economic*.mp. or cost*.ti.
33. or/1-5
34. or/6-32
35. S33 and S34.
36. ((intrancranial or intraocular or pulmonary or portal) adj1 hypertension).mp.
37. exp hypertension/si [Side Effect]
38. (developing-countr* or third-world).mp. or india.in. or bangladesh.in.
39. (bangladesh* or salvador* or panama* or nicaragua* or belize or mexico or costa-rica*).mp.
40. (china or chinese or pakistan* or india or africa or mexico or brazil or brasil or argentina or guatemala or morocco).mp.
41. exp Africa/ or . exp South America/
42. cuba/ or haiti/ or exp central america/ or exp panama/ or exp asia, central/ or borneo/ or cambodia/ or east timor/ or indonesia/ or laos/ or malaysia/ or mekong valley/ or myanmar/ or philippines/ or thailand/ or vietnam/ or india/ or sikkim/ or afghanistan/ or iran/ or iraq/ or jordan/ or lebanon/ or syria/ or turkey/ or yemen/ or nepal/ or pakistan/ or sri lanka/ or exp china/ or exp korea/ or mongolia/ or taiwan/ or exp transcaucasia/
43. or/36-42
44. S35 NOT S43 . limit to (english language and yr=”1980 -Current”)
Gateway (NLM); 287 Results
[Each line below was run as a separate search.]
Hypertension and out-of-pocket
Hypertension and insurance coverage
Hypertension cost sharing
Hyperlipidemia out-of-pocket
Antihypertensives out-of-pocket
Statins out-of-pocket
Value-based insurance hypertension
Database: NTIS (EbscoHost) 646 Results
S5 S1 AND S4
S4 S2 OR S3
S3 cover* OR complimentary OR free OR coupon* or discount* OR reduc* OR susidiz* OR subsidies OR subsidy OR subsidis* OR “out of pocket” OR “out-of-pocket OR copay* OR “co-pay*” OR gift* OR voucher* OR eliminat* OR “value-based” OR compensat* OR free OR incentiv* OR “cost sharing” OR “shared cost” OR “shared costs” OR “medication assistance program*” OR “pharmaceutical company assistance” OR “manufacturer* assistance” OR PMAPs OR uncompensated or indigen* OR “financially vulnerable” OR “medication possession” OR “cost assistance” or “fee reduction*” OR “reduc* fee*” OR “decreas** fee*” OR eliminat* OR “low income” OR “health benefits plan*” OR underserved OR urban
S2 cover* OR complimentary OR free OR coupon* or discount* OR reduc* OR susidiz* OR subsidies OR subsidy OR subsidis* OR “out of pocket” OR “out-of-pocket OR copay* OR “co-pay*” OR gift* OR voucher* OR eliminat* OR “value-based” OR compensat* OR free OR incentiv* OR “cost sharing” OR “shared cost” OR “shared costs” OR “medication assistance program*” OR “pharmaceutical company assistance” OR “manufacturer* assistance” OR PMAPs OR uncompensated or indigen* OR “financially vulnerable” OR “medication possession” OR “cost assistance” or “patient satisfaction” or “fee reduction*” OR “reduc* fee*” OR “decreas** fee*” OR eliminat* OR “low income” OR “health benefits plan*” OR underserved OR urban
S1 “high blood pressure” or hypertension or hyperlipidemia or “high cholesterol” or “blood fats” or “blood lipid” or “blood lipids” or “blood fat” or antihypertensive* or “anti-hypertensive*” or dyslipidemia or “high lipid*” or hyperlipid* or LDL or “lipid lowering” or “lower* lipid*” or “elevated lipid*” or “low lipid*” or “lower* cholesterol” or “total cholesterol” or “elevated cholesterol” or anticholester* or “cholesterol lower*”
Database: PAIS International ( ProQuest) 14 Results
((hypertension OR hyperlipidemia* OR “high cholesterol” OR “blood lipid*” OR “lipid level*” OR “elevated lipid*” OR “blood fat*” OR “high blood pressure” OR antihypertensive* OR “cholesterol-lowering” OR “lipid lower*” OR “lower lipid*”) AND (“reduced out-of-pocket” OR “reduced cost” OR “cost sharing” OR “shared cost*” OR payment* OR “co-payment*” OR copay* OR “co-pay*” OR “insurance benefit*” OR “insurance coverage” OR “patient incentive*” OR “financial assist*” OR discount* OR compensated OR compensation OR “prescription drug benefit*” OR “medication assistance” OR ” medication possession” or “patient satisfaction” or “pharmaceutical company assistance” OR “cost share” OR “subsidized payment*” OR “subsidized co-payment*” OR “medical indigence” OR “subsidized prescription*” OR “cost assistance” OR “fee reduction*” OR “medication cost* reduction*” OR “out-of-pocket” OR “value-based insurance” OR “reduced cost*” OR “health insurance incentive*” OR “health plan* incentive*” OR “reduc* fee” OR “prescription fee*” OR “value based” OR “spend* less” OR “lower spending” OR “low cost*” OR “lower* cost*” OR “less money” OR “lower fee*” OR “fee-free” OR “free medication*” OR “free drug*” OR “free prescription* or “free healthcare ” or “free health care” or ” prescription cover* ” or ” cover* prescription* ” or ” cover* medication* ” or “cover* cost* ” or ” cover* drug*” or “compensate* charge* OR “compensate* expense*” OR “cover* medical” OR “cost* compensat*” OR “expense compensat*” OR “free care” OR “free membership*” OR “free gym” OR “free gift*” OR “free insurance” OR “free medical” OR “va benefit*” OR “government provide*” OR “medicaid”)) AND la.exact(“ENG”)
Databases:
SYSTEM:OS – DIALOG OneSearch
File 35:Dissertation Abs Online 1861-2012/Jun
(c) 2012 ProQuest Info&Learning
File 65:Inside Conferences 1993-2012/Jul 05
(c) 2012 BLDSC all rts. reserv.
File 74:Int.Pharm.Abs 1970-2012/Jul B1
(c) 2012 The Thomson Corporation
File 426:LCMARC-Books 1968-2012/Jun W4
(c) format only 2012 Dialog
324 Results (total in all four database files)
S1 FREE()(DRUG? ? OR ACCESS OR CLASS? OR INSTRUCTION? ? OR MEMBERSHIP? ? OR COUNSEL? OR COVERAGE
S2 OUT(1W)POCKET
S3 (OUT)(2W)POCKET
S4 FREE()CARE OR VOUCHER? ? OR COUPON? OR COPAY? OR CO()PAY? OR WAIVER? ? OR SUBSIDY OR SUBSIDIES OR SUBSIDIS? OR SUBSIDIZ?
S5 REDUC?()COST? ? OR REDUC?(2N)COST?
S6 FINANCIAL()ASSISTANCE OR DEFRAY(2N)COST? ? OR REDUC?()HEALTHCARE()COST? ? OR REDUC?()HEALTH()CARE()COST? ? OR FEE()(FREE OR REDUC?) OR FREE()FEE? ? OR REDUC?()FEE? ? OR INSURANCE()INCENTIVE? ? OR VALUE-BASED OR INDIGENCE OR INDIGENCY OR INDIGENT? ? OR LOWER()COST? ? OR LOWER()PAYMENT? ? OR MEDICATION()POSESSION OR PATIENT()SATISFACTION OR PHARMACEUTICAL()COMPANY()ASSISTANCE OR COST()SHARING OR SHARE? ?()COST? ?
S7 HYPERTENSION OR HYPERLIPIDEMIA? ? OR HYPERLIPIDAEMIA? ? OR ANTI()HYPERTENSIVE? ? OR ANTIHYPERTENSIVE? ? OR HIGH()CHOLESTEROL OR CHOLESTEROL()LOWERING OR BLOOD()FAT? ? OR LIPID()LEVEL? ? OR ELEVATED()LIPID? ? OR LOWER?()CHOLESTEROL OR DYSLIPIDEMIA OR LIPID()LOWER? OR BLOOD()LIPID? ? OR LOWER()LIPID?
S8 S1 OR S2 OR S3 OR S4 OR S5 OR S6
S9 S S7 AND S8
S10 S S9/1980:2012
35: Dissertation Abs Online_1861-2012/Jun
62 S9
1776104 PY=1980 : PY=2012
62 S9/1980:2012
65: Inside Conferences_1993-2012/Jul 05
1 S9
7927660 PY=1980 : PY=2012
1 S9/1980:2012
74: Int.Pharm.Abs_1970-2012/Jul B1
262 S10
486956 PY=1980 : PY=2012
259 S10/1980:2012
426: LCMARC-Books_1968-2012/Jun W4
2 S9
10240086 PY=1980 : PY=2012
2 S9/1980:2012
TOTAL: FILES 35,65,74, and 426
327 S9
20430806 PY=1980 : PY=2012
S11 324 S9/1980:2012
Database: Web of Science; Results 2306
#13 (#11 NOT #12) AND Language=(English)
#12 TI=(India or Bangladesh or “South Africa*” or Nigeria)
#11 (#9 NOT #10) AND Language=(English)
#10 TS=(“portal hypertension” or “intraocular hypertension” or “intracranial hypertension” or “ocular hypertension)
#9 #5 AND #1
Refined by: Countries/Territories=(USA OR SINGAPORE OR HONG KONG OR ENGLAND OR CANADA OR ITALY OR AUSTRALIA OR PORTUGAL OR FRANCE OR SWEDEN OR JAPAN OR FED REP GER OR NETHERLANDS OR AUSTRIA OR GERMANY OR SWITZERLAND OR SPAIN OR BELGIUM OR WALES OR NEW ZEALAND OR GREECE OR NORTH IRELAND OR SCOTLAND OR DENMARK OR SOUTH KOREA OR NORWAY OR POLAND OR ISRAEL OR U ARAB EMIRATES OR SAUDI ARABIA OR FINLAND OR IRELAND) AND [excluding] Web of Science Categories=(AGRICULTURE DAIRY ANIMAL SCIENCE OR OCEANOGRAPHY OR PHYSICS MULTIDISCIPLINARY OR ECOLOGY OR VETERINARY SCIENCES) AND [excluding] Web of Science Categories=(FISHERIES OR ZOOLOGY OR ENERGY FUELS)
#8 #5 AND #1
Refined by: Countries/Territories=(USA OR SINGAPORE OR HONG KONG OR ENGLAND OR CANADA OR ITALY OR AUSTRALIA OR PORTUGAL OR FRANCE OR SWEDEN OR JAPAN OR FED REP GER OR NETHERLANDS OR AUSTRIA OR GERMANY OR SWITZERLAND OR SPAIN OR BELGIUM OR WALES OR NEW ZEALAND OR GREECE OR NORTH IRELAND OR SCOTLAND OR DENMARK OR SOUTH KOREA OR NORWAY OR POLAND OR ISRAEL OR U ARAB EMIRATES OR SAUDI ARABIA OR FINLAND OR IRELAND) AND [excluding] Web of Science Categories=(AGRICULTURE DAIRY ANIMAL SCIENCE OR OCEANOGRAPHY OR PHYSICS MULTIDISCIPLINARY OR ECOLOGY OR VETERINARY SCIENCES)
#7 #5 AND #1
Refined by: Countries/Territories=(USA OR SINGAPORE OR HONG KONG OR ENGLAND OR CANADA OR ITALY OR AUSTRALIA OR PORTUGAL OR FRANCE OR SWEDEN OR JAPAN OR FED REP GER OR NETHERLANDS OR AUSTRIA OR GERMANY OR SWITZERLAND OR SPAIN OR BELGIUM OR WALES OR NEW ZEALAND OR GREECE OR NORTH IRELAND OR SCOTLAND OR DENMARK OR SOUTH KOREA OR NORWAY OR POLAND OR ISRAEL OR U ARAB EMIRATES OR SAUDI ARABIA OR FINLAND OR IRELAND)
#6 #5 AND #1
#5 #4 OR #3 OR #2
#4 (TI=(cost* or economic or urban or compensat*)) AND Language=(English)
#3 (TS=(coupon or coupons or “medical coverage*” or “expense* cover*” or “cost cover*” or “drug cover*” or “prescription cover*” or “medication cover*” or “compensated or “compensat* cost” or “compensate* fee*” or “patient* cost*” or “free health care” or “free healthcare” or “free prescription*” or “free medicine*” or “free medication*” or “free drug*” or voucher* or “free coverage* or “free gift*” or “free insurance” or “government provid*” or “free medical” or “va benefit*” or “veteran* benefit*” or “veteran* administration*” or “program provid*” or “eliminat* cost*” or “cost reduc*” or “cost eliminat*” or “eliminat* charge*” or “cost adjust*” or “value based” or “copay*” or “co-pay*” or “medication assistance” or “medication possession” or “patient satisfaction” or “prescription fee*” or “pharmaceutical fee*” )) AND Language=(English)
#2 (TS=(reduc* healthcare cost*” or “insurance incentive*” or “health plan incentive*” or “uncompensated care” or “free medication*” or “free medicine*” or “free drug*” or “free prescription*” or “free hospital*” or “free clinic*” or “subsidized medication*” or “subsidized medicines” or “subsidized drug*” or “subsidized antihypertensive*” or medical* indigenc*” or “free prescription*” or “subsidiz* prescription*” or “cheap* prescription*” or “low* price” or “reduc* cost*” or “fee reduction*” or “reduc* fee*” or “out-of-pocket” or “out of pocket” or “oop cost*” or “oop-cost*” or “decrease* fee*” or subsidy or subsidies or subsidize* or subsidise* or complimentary or indigence or indigent* or “low-cost*” or “lower-cost*” or “fee-free” or “less-money” or “lower* fee*” or “assistance fund*” or “lower spending” or “spent less” or dollar* or “reduc* fee”)) AND Language=(English)
#1 TS=(hypertension or hyperlipidemia* or “high blood pressure” or “high cholesterol” or “blood lipid*” or “blood fats”) OR TS=(“cholesterol lowering” or “lower* cholesterol” or antihypertensive* or “anti-hypertensive*” or “lipid-level*” or “elevated-lipid*”)
Database: Scopus; Results: 1284
Date Searched: 7/14/2015
Search Strategy:
( ( ( ( KEY ( hypertension OR hyperlipidemia* OR “high blood pressure” OR “high cholesterol” OR “blood lipid*” OR “blood fats” OR “cholesterol lowering” OR “lower* cholesterol” OR antihypertensive* OR “anti-hypertensive*” OR “lipid-level*” OR “elevated-lipid*” ) AND PUBYEAR > 2011 ) AND ( ( ( TITLE-ABS-KEY ( hypertension OR hyperlipidemia* OR “high blood pressure” OR “high cholesterol” OR “blood lipid*” OR “blood fats” OR “cholesterol lowering” OR “lower* cholesterol” OR antihypertensive* OR “anti-hypertensive*” OR “lipid-level*” OR “elevated-lipid*” ) AND PUBYEAR > 2011 ) AND ( ( TITLE-ABS-KEY ( cost ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( cheap OR cheaper OR ( less n/1 cost* ) OR coupon* OR voucher* OR ( low n/1 income* ) OR price* OR ( financial n/1 assistance ) OR subsidized OR subsidy OR subsidies OR subsidised ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( discount* OR compensated OR complimentary OR ( co n/1 pay* ) OR copay* OR insurance OR fee OR fees OR gift OR gratis OR indigence OR indigent* indigency OR ( medication n/1 assistance ) OR ( medication n/1 possession ) ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( discount* OR compensated ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( complimentary OR ( co n/1 pay* ) OR copay* ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( fee OR fees OR gift ) AND PUBYEAR > 2011 ) OR ( TITLE ( gratis OR indigence OR indigent* OR indigency ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( urban ) AND PUBYEAR > 2011 ) ) ) AND ( TITLE-ABS-KEY ( hypertension OR hyperlipidemia* OR “high blood pressure” OR “high cholesterol” OR “blood lipid*” OR “blood fats” OR “cholesterol lowering” OR “lower* cholesterol” OR antihypertensive* OR “anti-hypertensive*” OR “lipid-level*” OR “elevated-lipid*” ) AND PUBYEAR > 2011 ) ) ) AND ( ( KEY ( cost ) AND PUBYEAR > 2011 ) OR ( TITLE ( cheap OR cheaper OR ( less n/1 cost* ) OR coupon* OR voucher* OR ( low n/1 income* ) OR price* OR ( financial n/1 assistance ) OR subsidized OR subsidy OR subsidies OR subsidised ) AND PUBYEAR > 2011 ) OR ( KEY ( discount* OR compensated OR complimentary OR ( co n/1 pay* ) OR copay* OR fee OR fees OR gift OR gratis OR indigence OR indigent* indigency OR ( medication n/1 assistance ) OR ( medication n/1 possession ) ) AND PUBYEAR > 2011 ) OR ( KEY ( discount* OR compensated ) AND PUBYEAR > 2011 ) OR ( KEY ( complimentary OR ( co n/1 pay* ) OR copay* ) AND PUBYEAR > 2011 ) OR ( KEY ( fee OR fees OR gift ) AND PUBYEAR > 2011 ) OR ( KEY ( gratis OR indigence OR indigent* OR indigency ) AND PUBYEAR > 2011 ) OR ( KEY ( urban ) AND PUBYEAR > 2011 ) ) ) AND NOT ( ( TITLE ( hypertension OR hyperlipidemia* OR “high blood pressure” OR “high cholesterol” OR “blood lipid*” OR “blood fats” OR “cholesterol lowering” OR “lower* cholesterol” OR antihypertensive* OR “anti-hypertensive*” OR “lipid-level*” OR “elevated-lipid*” ) AND PUBYEAR > 2011 ) AND ( ( TITLE ( cost ) AND PUBYEAR > 2011 ) OR ( TITLE ( cheap OR cheaper OR ( less n/1 cost* ) OR coupon* OR voucher* OR ( low n/1 income* ) OR price* OR ( financial n/1 assistance ) OR subsidized OR subsidy OR subsidies OR subsidised ) AND PUBYEAR > 2011 ) OR ( TITLE-ABS-KEY ( discount*or compensated OR complimentary OR ( co n/1 pay* ) OR copay* OR cover* OR eliminat* OR fee OR fees OR gift OR gratis OR indigence OR indigent* indigency OR ( medication n/1 assistance ) OR ( medication n/1 possession ) ) AND PUBYEAR > 2011 ) OR ( TITLE ( discount* OR compensated ) AND PUBYEAR > 2011 ) OR ( TITLE ( complimentary OR ( co n/1 pay* ) OR copay* ) AND PUBYEAR > 2011 ) OR ( TITLE ( fee OR fees OR gift ) AND PUBYEAR > 2011 ) OR ( TITLE ( gratis OR indigence OR indigent* OR indigency ) AND PUBYEAR > 2011 ) OR ( TITLE ( urban ) AND PUBYEAR > 2011 ) ) ) ) AND ( LIMIT-TO ( LANGUAGE , “English” ) ) AND ( LIMIT-TO ( AFFILCOUNTRY , “United States” ) OR LIMIT-TO ( AFFILCOUNTRY , “United Kingdom” ) OR LIMIT-TO ( AFFILCOUNTRY , “Italy” ) OR LIMIT-TO ( AFFILCOUNTRY , “Canada” ) OR LIMIT-TO ( AFFILCOUNTRY , “Germany” ) OR LIMIT-TO ( AFFILCOUNTRY , “France” ) OR LIMIT-TO ( AFFILCOUNTRY , “Japan” ) OR LIMIT-TO ( AFFILCOUNTRY , “Australia” ) OR LIMIT-TO ( AFFILCOUNTRY , “Spain” ) OR LIMIT-TO ( AFFILCOUNTRY , “Netherlands” ) OR LIMIT-TO ( AFFILCOUNTRY , “Switzerland” ) OR LIMIT-TO ( AFFILCOUNTRY , “South Korea” ) OR LIMIT-TO ( AFFILCOUNTRY , “Belgium” ) OR LIMIT-TO ( AFFILCOUNTRY , “Sweden” ) OR LIMIT-TO ( AFFILCOUNTRY , “Denmark” ) OR LIMIT-TO ( AFFILCOUNTRY , “Austria” ) OR LIMIT-TO ( AFFILCOUNTRY , “New Zealand” ) OR LIMIT-TO ( AFFILCOUNTRY , “Finland” ) OR LIMIT-TO ( AFFILCOUNTRY , “Ireland” ) OR LIMIT-TO ( AFFILCOUNTRY , “Norway” ) OR LIMIT-TO ( AFFILCOUNTRY , “Czech Republic” ) OR LIMIT-TO ( AFFILCOUNTRY , “Portugal” ) )
Database: Worldcat.org; Results: 20
Date Searched: 7/15/2015
Search Strategy:
Limit to 2012-2015
Limit to English language
Antihypertensive* or lipid* or cholesterol or dyslipidemia or “high blood pressure: or antihypertensive* or hypertension or hyperlipidemia or blood fat
AND
Cost* or copay* or co-pay* or coupon* or voucher* or “out of pocket” or discount* or indegen* or “financial assistance: or “medication possession” or fee or fees or subsid*
Review References
McEwan P, Peters JR, Bergenheim K, Currie CJ. Evaluation of the costs and outcomes from changes in risk factors in type 2 diabetes using the Cardiff stochastic simulation cost-utility model (DiabForecaster). Curr Med Res Opin 2005;22(1):121-9.
Considerations for Implementation
- Program or policy changes can be made by many implementers, including insurance companies, government agencies, and employers.
- To increase awareness and use of covered services, it is important to promote these programs and policies to both patients and providers.
- Broad programs and policies that reduce out-of-pocket costs to reduce patients’ overall cardiovascular disease risks should coordinate coverage for blood pressure and cholesterol management with coverage for the following:
- Diabetes management
- Evidence-based tobacco cessation treatments
- ROPC combined with additional interventions, such as medication counseling, may increase opportunities for patient-provider interaction on treatment issues.
CDC’s Division for Heart Disease and Stroke Prevention developed Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effective Health Care System Interventions and Community-Clinical Links to help communities select and implement successful interventions. The guide summarizes the effectiveness and economic evidence behind eight strategies to prevent cardiovascular disease, including reducing out-of-pocket costs for preventive services for patients with high blood pressure and high cholesterol. For each strategy, the guide offers information on implementation, such as settings where the strategies have been successful, resources available to support implementation, and policy considerations. “Stories from the Field” feature specific settings where strategies have been successfully implemented.
Crosswalks
Healthy People 2030
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.