The employer-level “intent-to-treat” cohort study by Duru et al. evaluated the impact of an employer-initiated disease management program, the Diabetes Health Plan (DHP), on adherence to diabetes-related medications.1 Using a quasi-experimental design, the investigators estimated employer-level adherence post-initiation of DHP for three medications covered by the DHP (metformin, statins, ACE/ARBs) and two medications not covered by the DHP (thyroxine, montelukast). The DHP provided enrolled participants discounted copayments for medications and provider visits, and access to online or telephone wellness coaching. There was a modest improvement in adherence to the three DHP-covered medications after 1 year.

While these results contribute to the existing literature on the inverse relationship between medication copayments and adherence,2 – 4 future research should test whether the modest improvement in adherence translates to clinical and economic benefits. Previous studies have suggested that lower out-of-pocket medication expenditures are associated with improved adherence, but not necessarily enough to reduce overall medical spending for patients and payers.3 , 5 Future studies on the DHP may include, as the investigators note, return-on-investment (ROI) analyses focusing on outcomes such as changes in rates of hospitalization, emergency department visits, absenteeism, and short-term disability.

However, a truly comprehensive assessment of a benefit design package such as the DHP would include not only the employer perspective, but also the patient perspective. Ultimately, a diabetes intervention such as the DHP should maximize the health of a population by slowing disease progression, increasing survival and quality of life, and reducing costs to the employer and health plan. Outcomes such as clinical markers of benefit (HbA1c, blood pressure, LDL cholesterol, etc.), patient preferences, survival, and patient-reported satisfaction—paired with employer-level outcomes—would form a complete picture of the tradeoffs associated with investing in the DHP.

For employers and health plans, this study provides evidence of a benefit design plan that can improve adherence for employees with diabetes. To determine whether the DHP is truly a scalable and affordable health plan for employers and health plans to purchase, it will be necessary to make the connection between adherence and outcomes that are relevant to decision-makers and patients.