The Paradox of Choice in Health Care

William H. Shrank, M.D., M.S.H.S., discusses the role of patient choice in pharmacy benefit management.

When does optimizing choice improve patient access and health?

Americans demand choice. No one wants someone else telling them where to shop or what to watch, wear or eat.  But, when it comes to health care, too much choice can have a negative impact, and not all choice is created equal.

In an article published in Catalyst, an online publication from the New England Journal of Medicine, I explored the evidence about the role of choice in pharmacy benefits. The article examines research that shows both where choice in benefit plan design is essential but also where it can adversely affect patient health.

Retail vs. Mail: Patients Should Choose the Access Channel

We know that patients have strong preferences on how they get their medications. This is more than just a matter of convenience as research has shown that offering patients the flexibility to pick up their medications in-store or receive them by mail (for the same copay) can also lead to improved medication adherence.

Optimizing Choice: Plan Design Opportunities

Formulary Strategies
Even though the majority of Americans believe that in general people should use generic medications, far fewer actually prefer to use generics themselves. This can have a major impact on consumer wallets and payers’ budgets. To address this, benefit managers often employ tiered formulary strategies that encourage the use of less expensive (but still equally effective) generic drug options.

While you may think that fewer options would lead to poorer outcomes, research underscores the importance of efforts to encourage generic use. Not only do generic medications save the health care system money, but patients are more likely to take medicines as prescribed when they are more affordable, leading to improved adherence and better clinical outcomes. In addition, our own research found that more selective drug formularies can boost adherence to essential therapies. Conversely, when patients are given too many choices or are prescribed expensive, brand-name medications, they often experience “sticker shock” and, as a result, choose not to pick up their medication or take it as prescribed.

Network Solutions
We also recently examined the impact of narrow or preferred pharmacy networks on patient outcomes. This plan design option, in which patients pay lower copays when they fill their prescriptions at certain pharmacies vs. a broad, all-encompassing pharmacy network, is often criticized for limiting patient access. However, our research showed that implementation of these networks improved patients’ medication adherence as the patients are more likely to establish a pharmacy home where they can receive coordinated pharmacy care and disease management support leading to better health. 

Although it seems counterintuitive to conventional wisdom, research shows that too much choice can have negative and costly impacts on health. Health care is often just too complex to be able to engage patients in every aspect of their care. At CVS Health, we recognize the importance of choice with a focus on improving convenience and engaging patients to help foster healthier behaviors and improve health outcomes.