THE COST FACTOR AND GENERICS
From the employer side, are costs a factor in low rates of adherence?
We recognize that high copays for drugs can be a barrier to compliance. To help patients avoid high copays, we're seeing the
major pharma companies offer discount cards or rebate coupons directly to the patient. This can make the medicine more affordable,
but for us as purchasers it can cost us more money because it hampers our ability to design benefits that will drive our insured
population to lower-priced generics.
What is needed is a payment system that rewards cognitive dialogue with the patient about medications they have been prescribed.
Physicians are paid for procedures and tests but not for providing patient-centered advice about medications. There is no
billable code or mechanism to incentivize a discussion on prescribed medications as part of an office visit. It should be
ED PEZALLA, MEDICAL DIRECTOR FOR POLICY AND STRATEGY, AETNA:
Rising copays for patients can lead them to forgo many elements of basic care, particularly on the prevention side. Health Affairs published a study last month with support from Brigham and Women's Hospital that show higher copays do lower costs to the
insurer, but the overall impact is marginal. The results have motivated us to put more emphasis on adherence programs in a
new benefit design platform we are rolling out in the context of health insurance reform. And we still don't have a good read
from a data point of view on the impact of lowering copays on adherence.
Researchers from The Rand Corp. published work in JAMA that found for every 10 percent increase in copayments for drugs, rates of adherence dropped by between 2 percent and 6 percent.
Yet it is also true that in countries where medications are basically free to the patient, there is essentially the same level
Many patients take multiple medications. How does that factor into adherence?
A factor that drives cost is that combination pills are often more expensive than single source medications. For example,
patients want to know why Janumet is more costly than taking Januvia and Metformin separately. Is it purely a convenience
factor? Is there a real clinical benefit? The patient wants answers to questions like these.
The average diabetic is taking six-and-one-half drugs on a daily basis.
Our focus group work finds that patients are worried about the overall "pill burden." A large percentage of our respondents
seem to hit a certain limit, say seven drugs, where they say "no more." The problem is that some patients will scrap precisely
the wrong drug(s). They are not in a position to differentiate clinical value, like dropping their blood pressure medicine
because they must take a one-week course for an antibiotic.
Specialty drugs and biologics are going to constitute a larger proportion of prescribing in the years ahead. How will this
impact the rate of adherence?
These drugs are very costly—the fastest-growing segment of drug spend for any payer/employer. We have commissioned a study
on biologics drug management to identify how benefit designs can ensure only those whose clinical status necessitates them
receiving the medications and those that do get the drugs have the educational tools and support to make certain the medications
are used appropriately. We are also looking at programs that use nurses or pharmacists to intervene to evaluate the progress
of therapy shortly after the initial fill toward the intended outcome. It's unsustainable to provide coverage to these expensive
drugs and then find our patients fail to adhere.