title: Systematic review of benefit designs with differential cost sharing for prescription drugs.
abstract: OBJECTIVE
  To evaluate the effects of health insurance benefit designs that introduced or increased the price difference between prescription drugs representing potential clinical substitutes.
  
  
  METHODS
  Systematic review of peer-reviewed articles.
  
  
  METHODS
  Using English-language articles listed in PubMed between 1980 and 2012, we identified articles meeting our inclusion criteria and minimum methodological standards. We compared findings regarding the immediate patient response, total spending, and health outcomes after implementing the price change.
  
  
  RESULTS
  Among the 31 articles identified, the mechanisms varied for creating the price differential between prescription drug substitutes, though they most frequently involved tiered formularies (19) or reference pricing (10). While nearly all studies (29 of 31) reported on patient responses to price changes, only 5 articles comprehensively assessed patient price responses, total spending, and health outcomes. Several studies found that some patients switched to cheaper drugs, but out-of-pocket spending increased on average, suggesting that other patients continued using the more expensive drug (ie, cost shifting to patients). Few studies examined the degree of heterogeneity in behavior responses, especially between patient cohorts for whom the substitute drugs had varying value. Some studies observed long-term effects, but most had limited post intervention observation periods.
  
  
  CONCLUSIONS
  Differential cost-sharing designs influence drug use behavior, but there is limited evidence on how these designs affect the overall value of received care. The existing literature provides limited guidance for policy makers or organizational leaders to design benefits. We offer suggestions for future studies to inform policy and practice.
authors.forename: Oluwatobi Awele
authors.initials: OA
authors.lastname: Ogbechie
authors.affiliation: Mongan Institute for Health Policy, Massachusetts General Hospital, Harvard Medical School, 50 Staniford St, Rm 901B, Boston, MA 02114. E-mail: jhsu7@partners.org.
authors.forename: John
authors.initials: J
authors.lastname: Hsu
mesh_terms: D017047:Cost Sharing / Q000379:methods* / Q000706:statistics & numerical data*; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000706:statistics & numerical data*