The future of prescription drug cost-sharing: real progress or dropped opportunity?

It was October 25, 1986. Game 6 of the World Series between the New York Mets and the Boston Red Sox was tied in the bottom of the 10th inning, with 2 outs and 1 runner on base. The Mets’ Mookie Wilson hit a routine grounder in the direction of first baseman Bill Buckner, who bent down to scoop it up. But in one of the most infamous incidents in sports history, the ball sailed past Buckner’s outstretched glove and rolled through his legs into right field. The Mets scored, won the ball game, and eventually took the Series title. The Sox did not make another trip to the World Series until 2004. Their critical moment of opportunity had been lost.1 Managed care pharmacy currently faces a critical moment of opportunity as it considers the future of cost-sharing for prescription drugs. Nearly every serious observer of health care outcomes research understands that decisions about patient out-of-pocket (OOP) cost should be based on evidence. But what is less universally recognized is the importance of catching the right evidence to avoid dropping the ball in today’s cost-sharing game. The key to understanding our industry’s challenge (and opportunity) lies in recognizing that a paradigm transition is underway in both business and academic sectors of health care policymaking. A once almost universally held view, that generic/brand cost-share differentials and increases in cost-sharing to keep pace with inflation are the best tools to align consumer behavior with desired clinical and economic outcomes, is gradually being challenged by a new model of patient incentives. According to this new model, reduction or elimination in cost-sharing for prescription drugs has the potential to cure ills ranging from patient noncompliance to rising costs for medical services.2 As an industry, we can either respond to the paradigm shift to ensure that our bases are covered or risk dropping the ball.