Does Free Medicines Coverage Improve Diabetes Self-Care and Outcomes for Diverse Populations?

项目摘要/摘要 药物的经济负担是坚持用药和随后的糖尿病的一个重要障碍。 控制力。福利设计，减少被视为更具成本效益的服务的共付金(称为 “基于价值的保险设计”或VBID)继续吸引公共和私营保险公司的注意， 雇主和政策制定者将其作为提高遵从性和降低长期成本的战略。而VBID 减少慢性病药物共同支付的计划被证明有积极的不足- 长期影响用药依从性，我们对临床收益随着时间的推移的长期可持续性了解较少， 特别是在激励措施被取消的情况下。此外，人们对哪些因素会影响谁参与以及 当VBID计划在现实世界、多雇主环境中通过健康计划引入时，世卫组织将受益。这 研究将评估一项名为WellRx药物的现实世界VBID计划的提供和终止情况 Rider--零共同支付药物福利，旨在让患者更有效地进行自我护理。 为了利用这一独特的自然实验，我们将使用多方法方法，包括患者- 邮寄调查，对患者、提供者和雇主的半结构化访谈，以及准试验性 应用前后对照和患者水平中断时间序列的纵向研究 比较系列，以评估WellRx对糖尿病患者的影响。这项研究的动机是 四个具体目标： (1)研究雇主参与WellRx计划的决定因素及 并评估高危患者亚组之间的差异(例如，种族和社会经济 状态)； (2)检查自我管理、利用和成本以及临床结果(糖化血红蛋白、血脂、 血压控制)超过1年的基线和长达4年的随访，比较 与倾向匹配的患者相比，雇主提供免费计划；(3) 评估计划终止后结果的可持续性，比较雇主的患者 继续或选择在以后的后续年份停止WellRx保险；以及(4)确定 在目标2和目标3中观察到的变化因种族/民族、收入、教育程度或基线而不同 不坚持。 这项拟议的研究解决了现实世界卫生系统中的务实问题，该系统高度有动力 改善不同人群糖尿病患者获得护理的机会、自我效能和预后。我们的 这些发现将为未来创建福利设计的努力提供参考，这些设计得到提供商的认可，符合患者的需求， 解决患者参与的障碍，并提高患者保持有效控制糖尿病的能力。

PROJECT SUMMARY/ABSTRACT The financial burden of medications is a significant barrier to medication adherence and subsequent diabetes control. Benefit designs that reduce copayments for services that are seen to be more cost-effective (known as “value-based insurance designs” or VBIDs) continue to capture the attention of public and private insurers, employers, and policy makers as a strategy to improve adherence and reduce long-term costs. While VBID programs that reduce copayments for chronic illness medications have been shown to have a positive short- term impact on medication adherence, we know less about long-term sustainability of clinical gains over time, particularly when incentives are eliminated. Also, little is known about which factors affect who participates and who benefits when VBID programs are introduced by a health plan in a real-world, multi-employer setting. This study will evaluate the provision and discontinuation of a real-world VBID program called the WellRx Drug Rider -- a zero copay drug benefit offered to engage patients more effectively in their self-care. To take advantage of this unique natural experiment, we will use a multi-method approach including patient- mailed surveys, semi-structured interviews of patients, providers, and employers, and a quasi-experimental longitudinal study using pre-post with comparison group and patient-level interrupted time series with comparison series to evaluate the impact of WellRx among patients with diabetes. This study is motivated by four specific aims: (1) to examine determinants of decisions about WellRx participation among employers and patients with diabetes and assess differences in at-risk patient subgroups (e.g., race and socioeconomic status); (2) to examine changes in self-management, utilization and costs, and clinical outcomes (HbA1c, lipid, blood pressure control) over a 1-year baseline and up to 4-year follow-up, comparing patients whose employers offered the free program compared to propensity-matched patients whose employers did not; (3) to assess sustainability of outcomes following program discontinuation, comparing patients whose employers continue or choose to discontinue WellRx coverage in later follow-up years; and (4) to determine whether the changes observed in Aims 2 and 3 differ by race/ethnicity, income, education attainment, or baseline nonadherence. The proposed study addresses pragmatic questions in a real-world health system that is highly motivated to improve access to care, self-efficacy, and outcomes for a diverse population of patients with diabetes. Our findings will inform future efforts to create benefit designs that are provider-endorsed, align with patient needs, address barriers to patient engagement, and improve patient capacity to maintain effective diabetes control.