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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

Task Force Finding

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.

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.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

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.

Definition

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), and 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.

About the Systematic Review

The Task Force finding is based on evidence from a systematic review of 31 studies with 35 study arms (search period: beginning of database – July 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Results

  • Eighteen included studies were stratified based on suitability of study designs, as defined by the Task Force (Briss et al., 2000). Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.
  • 12 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).
  • 6 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 (interquartile interval [IQI]: 2.3 to 4.5; 6 studies, 15 arms).
  • Proportion of patients achieving 80% adherence
    • Greatest/moderate suitability studies: increase of 5.1 pct pts (1 study)
Blood Pressure
  • Patients' systolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 5.9 mmHg (range: -10.7 to 3.8; 4 studies)
    • Least suitability studies: decrease of 8.7 mmHg (IQI: -14.5 to -5.5 mmHg; 6 studies)
  • Patients' diastolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 3.8 mmHg (range: -6.1 to -2.1 mmHg; 4 studies)
    • Least suitability studies: median decrease of 4.5 mmHg (IQI: -7.8 to -3.8 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 pct pts (range: -8.2 to 17.0 pct pts; 3 studies)
    • Least suitability studies: median increase of 30.1 pct pts (IQI: 20.3 to 46.5 pct pts; 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 (range: -16.0 to -6.9 mg/dL; 3 studies)
    • Least suitability of design: median decrease of 14 mg.dL IQI: -18.9 to 10.9 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 pct pts; 2 studies
    • Least suitability studies: increase of 10 pct pts; 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

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 nine studies, seven of which evaluated reducing out-of-pocket costs within a value-based insurance design. Two of the nine studies combined reduced cost for medications with team-based care and three combined VBID with support for disease or lifestyle management, with only one study providing separate estimates for the cost to implement the component interventions. Monetary values are reported in 2014 U.S. dollars.

  • Three studies of VBID reported net benefits, with 2 showing the cost of intervention exceeded averted health care costs by $337 and $90 per patient per year, and the third showing the intervention was cost-neutral.
  • No studies reported cost-effectiveness results.
  • The median intervention cost per person per year was $172 (IQI: $70 to $529, n = 10), 9 studies.
    • The higher estimates included blood pressure-lowering and diabetes medications.
  • Median change in health care cost was –$127 (IQI: –$632 to –$18, n = 8), 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.

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

Supporting Materials

Publications

Njie GJ, Finnie RK, Acharya SD, Jacob V, Proia KK, Hopkins DP, et al. Reducing medication costs to prevent cardiovascular disease: a Community Guide systematic review Adobe PDF File [PDF - 291 kB]. Preventing Chronic Disease 2015; 12:150242.

Fielding JE, Rimer BK, Johnson RL, Orleans CT, Calonge N, Clymer JM, et al. Recommendation to reduce patients' blood pressure and cholesterol medication costs Adobe PDF File [PDF - 264 kB]. Prev Chronic Dis 2015;12:150253.

Read other Community Guide publications about Cardiovascular Disease Prevention and Control in our library.

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; updated July 2015