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Cardiovascular Disease Prevention and Control: Reducing Out-of-Pocket Costs for Cardiovascular Disease Preventive Services for Patients with High Blood Pressure and High Cholesterol

Reducing out-of-pocket costs (ROPC) for patients with high blood pressure and high cholesterol involves program and policy changes that make cardiovascular disease preventive services more affordable. These services include:

  • 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 health care 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 such as team-based care, medication counseling, and patient education. Program and policy changes may be communicated to patients and providers using targeted messages to increase awareness and use of covered services.

Summary of Task Force Recommendations and Findings

The Community Preventive Services Task Force recommends reducing patient out-of-pocket costs (ROPC) for medications to control high blood pressure and high cholesterol when combined with additional interventions aimed at improving patient–provider interaction and patient knowledge, such as team-based care with medication counseling, and patient education. This recommendation is based on strong evidence of effectiveness in improving (1) medication adherence and (2) blood pressure and cholesterol outcomes.

Limited evidence was available to assess the effectiveness of reducing patient out-of-pocket costs for behavioral counseling or behavioral support services independent of reducing patient costs for medications.


Task Force Finding and Rationale Statement

About the Intervention

  • Patients' out-of-pocket costs are reduced by establishing programs and policies to provide blood pressure and cholesterol lowering medications at no cost (e.g., first dollar coverage) or reduced cost (e.g., a lower copayment).
  • Programs and policies that reduce out-of-pocket costs may be implemented by health plans, employers, and insurance companies.
  • Several studies evaluated the effect of reducing out-of-pocket cost within the context of a value-based insurance design. This insurance design reduces patients' out-of-pocket costs for medical services that are expected to be of greatest value for improving their health.
  • Team-based care and medication counseling are commonly implemented along with ROPC.

Considerations for Implementation

  • 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:
    • Diabetes management
    • Evidence-based tobacco cessation treatments

Results from the Systematic Review

Fourteen studies were included in the review. Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.

Medication Adherence

  • Patients' adherence to blood pressure and cholesterol-lowering medications increased by a median of 3.2 percentage points (interquartile interval [IQI]: 2.0 to 4.6; 3 studies, 10 arms).

Blood Pressure

  • Patients' systolic blood pressure decreased by a median of 8.7 mmHg (IQI: 1.9 to 10.9; 10 studies).
  • Patients' diastolic blood pressure decreased by a median of 4.5 mmHg (IQI: 3.0 to 6.1; 10 studies).
  • There was a median increase of 18.0 percentage points (IQI: 6.0 to 33.0) in the proportion of patients whose blood pressure was at the recommended goal (≤140/90 mmHg for people without diabetes and <130/80 mmHg for people with diabetes; 7 studies).

Cholesterol

  • Patients' total cholesterol decreased by a median of 20.0 mg/dl (range: 11.0 to 27.1; 4 studies).
  • Patients' low-density lipoprotein (LDL), the unhealthy cholesterol associated with increased risk of heart disease and stroke, decreased by a median of 14.0 mg/dl (IQI: 9.9 to 16.7; 6 studies).
  • There was a median increase of 13.0 percentage points (range: 10.0 to 24.7) in the proportion of patients whose LDL level was at the recommended goal (<100 mg/dl for most patients; 3 studies)
  • Patients' triglycerides decreased by a median of 29.0 mg/dl (IQI: 10.1 to 34.7; 5 studies).

Results from included studies are applicable to various groups with access to health care, including:

  • Adults (18-64 years old)
  • Women and men
  • Hispanic, white, and African-American patients
  • Low income patients

These results are based on a systematic review of all available studies, conducted on behalf of the Community Preventive Services Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention and control.

Economic Evidence

The economic review included five studies, three of which evaluated reducing out-of-pocket costs within a value-based insurance design. Monetary values are reported in 2011 U.S. dollars.

  • Three studies reported sufficient information to compute net benefits based on intervention cost and healthcare cost averted.
    • Two showed negative net benefits:
      • $87 per person per year for a value-based insurance design
      • $321 per person per year for a value-based insurance design combined with team-based care
    • One study reported a positive net benefit of $2,229 per person per year for patients with prior cardiovascular-related insurance claims.
  • Two studies provided intervention cost and reported pre- and post-intervention systolic blood pressure reductions that were used to estimate QALY saved using formulas from two trial-based modeling studies (Mason et al., 2005; McEwan et al., 2005;). For both of the studies, reduction in systolic blood pressure was measured pre- to post-intervention without a comparison group.
    • Cost per QALY saved was below a conservative threshold for cost-effectiveness of $50,000 for both studies (range: $9,395 to $30,544), indicating the interventions were cost-effective.

An overall economic conclusion cannot be reached, however, because the net benefit evidence is inconsistent and the two studies indicating cost-effectiveness were based on reductions in systolic blood pressure measured without a comparison group.

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for Community Guide publications on other topics.

Promotional Materials

Community Guide News

More promotional materials for Community Guide reviews about Cardiovascular Disease Prevention and Control.

References

Mason JM, Freemantle N, Gibson JM, New JP. Specialist nurse-led clinics to improve control of hypertension and hyperlipidemia in diabetes: economic analysis of the SPLINT trial. Diabetes Care 2005;28(1):40-6.

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.




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Cardiovascular disease prevention and control: reducing out-of-pocket costs for cardiovascular disease preventive services for patients with high blood pressure and high cholesterol. www.thecommunityguide.org/cvd/ROPC.html. Last updated: MM/DD/YYYY.

Review Completed: November 2012