A benefit-based copay for prescription drugs: Patient contribution based on total benefits, not drug acquisition cost

Several managerial mechanisms have been used by managed care organizations to affect prescription drug utilization and related expenditures. Some effo rts have focused on monitoring clinical conditions, drug use, and complianc e, whereas other efforts have focused on consumer cost sharing and changing product-mix. Efforts focusing on improving quality of care by identifying untreated patients or by enhancing compliance can lead to appropriately inc reased drug costs, although perhaps with reduced overall medical expenditur es. In contrast, the mechanisms implemented to constrain drug costs raise c oncerns regarding missed opportunities to enhance clinical outcomes, and th e possibility of higher medical expenditures. Cost sharing plays a critical role in defining the pharmaceutical benefit. To balance the demands for access to pharmaceuticals with pressures to cons train costs, levels of cost sharing must be set in a manner that achieves a ppropriate clinical and financial outcomes. Modern multitier systems often base patient contributions on drug acquisition cost, and often do not consi der medical necessity as a coverage criterion. Using an alternative approac h, the benefit-based copay, patient contributions are based on the potentia l for clinical benefit, taking into consideration the patient's clinical co ndition, For any given drug, patients with a high potential benefit would h ave lower copays than patients with a low potential benefit. Implementation of such a system would provide a financial incentive for individuals to pr ioritize their out-of-pocket drug expenditures based on the value of their medications, not their price.