Keep the single payer vision.

There is a widespread belief that the next step in health care reform is to inject market forces into our health care system to lower cost and improve quality. This assumes that the Patient Protection and Affordable Care Act (P-PACA) has solved our access problem, which it manifestly does not. The Congressional Budget Office estimates that 23 million people will remain uninsured in 2019, in spite of the expansion of Medicaid to those below 133% of the federal poverty level (FPL) and the provision of subsidies for those between 133% and 400% FPL. Nevertheless, those focused on implementing P-PACA have become deeply invested in pilots utilizing various cost sharing schemes and value-based insurance design. These pilots are directed at encouraging consumers to use “high-value therapies,” most often defined as low cost, high quality therapies. In terms of evaluating the effectiveness these strategies, most of the published studies have focused on prescription drug cost sharing. This approach to cost sharing is illustrated in the study reported in this issue of Medical Care by Martikainen, et al in which they demonstrate that patients and providers can be induced into using a lower cost statin in Finland by restricting reimbursement of high cost statins. Unfortunately, the study doesn’t go far enough, although the authors promise future studies. They candidly admit that they were “not able to assess the beneficial or adverse health effects” of restricted reimbursements for statins. For instance, did the shift from the more potent (and expensive) statin to the less potent (cheaper) statin result in more visits to the doctor, more hospitalizations because of myocardial infarctions or higher mortality? The study did show that the primary effect of restricted reimbursement was short-term cost containment. But will it yield long term over all savings for the health system? A much bolder and imaginative strategy would have been to provide statin therapy at no cost to the patient. This strategy has been tried with targeted populations, such as postacute myocardial infarction (AMI) patients as described by Choudhry et al. They found that the cost of prescription drugs borne by the patient was the central reason that only 50% of patients with coronary heart disease are adherent to their prescribed statin one year after an AMI. In a preliminary analysis of a study in which they eliminated cost sharing for statins and other medications recommended by practice guidelines (eg, aspirin, beta-blockers and ACE inhibitors) after an AMI, they showed that “the cost savings from clinical events that are averted by improved adherence may more than offset the incremental cost of full drug coverage (ie, the elimination of cost sharing). ” Martilainen et al demonstrated that restricted reimbursement for more expensive statins, like atorvastatin and rosuvastatin can result in short term cost savings for the health care system. But cost sharing has major limitations. As Rosenthal points out, “patients with high levels of cost sharing appear equally likely to cut back on essential health care services as on services of low or no value. ” For poor patients, even low levels of cost sharing can have even more devastating effects. Although this has led some to argue for value-based insurance design, I believe we need more creative strategies for bringing cost effective care into our health care system. We should consider eliminating all cost sharing, including coinsurance and deductibles. These tools designed to increase out-of-pocket expenditures for patients to make them “cost conscious,” also create access barriers to needed and un-needed health care equally.