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Diana Brixner, PhD, RPh, FAMCP

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Research Grant in Value Assessment and Health Outcomes Research, 2021 University of Utah

Understanding Patient Cost-Sharing Thresholds for High- and Low-Value Care Towards Development of a Value-Based Formulary


The process used to prefer certain products across drug classes for diabetes is generally focused on comparative effectiveness and cost. However, payers rarely tie patient preference for treatment attributes to formulary management, resulting in a misalignment of value as defined by providers, payers, and patients. Our study explores patient preferences and willingness to pay for treatment attributes of predetermined high-value and low-value medications within a health plan, in order to redefine value to incorporate patient preferences. A cross-sectional discrete choice experiment (DCE) questionnaire study design determined patient preferences for the benefit, risk, and cost attributes of type 2 diabetes treatments. A comprehensive literature review of patient preference studies in diabetes identified studied attributes, and a review of guidelines and medical literature identified clinical attributes. Patients and diabetes experts were interviewed and instructed to identify, prioritize, and comment on which attributes of diabetes medications were most important to them. From these interviews, a total of 7 attributes were selected for the dissemination for a DCE survey: 1) hemoglobin A1C reduction, 2) cardiovascular (CV) risk reduction, 3) heart failure (HF) risk reduction, 4) out-of-pocket cost, 5) route of administration, 6) dosing flexibility, and 7) gastrointestinal (GI) side effects. From the 58 health plan beneficiaries who responded to the DCE survey, patients preferred to be treated versus foregoing care. Attribute preferences such as cost, HF risk reduction, CV risk reduction, and GI side effects were found to be statistically significant. These survey results were used to calculate the willingness-to-pay thresholds to demonstrate which diabetic medications are preferred most by patients. These findings will then be compared with how the health plan ranks medications in order to compare where patients’ and health plans’ definitions of value are aligned and where differences arise. By aligning patient and stakeholder preferences, our study has the potential to yield improved patient outcomes and increase cost-savings to patients, beneficiaries, and health plans.

The funding from this PhRMA Foundation award has determined patient perspectives on the value of treatment options for diabetic medications compared to value assessment by a health plan. By further aligning provider, payer, and patient preferences, this study has the potential to yield improved clinical outcomes and increase cost-savings to patients, beneficiaries, and health plans.

Diana Brixner

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