Lowering drug copays is cost neutral but still beneficial

Reducing copayments for cardiovascular medications among low-risk patients appeared to be cost neutral, according to a study published online Oct. 3 in the Journal of the American College of Cardiology. Still, the policy change trimmed out-of-pocket expenditures and resource use.

At AHA.11, Niteesh K. Choudhry, MD, PhD, an associate physician at Brigham and Women’s Hospital in Boston, unveiled results from MI FREEE (Post-Myocardial Infarction Free Rx and Economic Evaluation), a randomized controlled policy study that evaluated whether lowering copayments for statins, beta-blockers and angiotensin II receptor blockers for patients recently discharged after an MI improved adherence, clinical outcomes and healthcare spending (N Engl J Med 2011;365:2088-2097). In that study, they found no significant difference between the fully covered group and the standard group for a first major vascular event or revascularization. But the fully covered group had better adherence, reduced rates of total major vascular events and reduced costs to patients, at no additional cost to the insurer.

The present study was designed by Choudhry and colleagues to investigate the impact of lowering copayments for evidence-based therapies among low-risk patients, taking advantage of a policy change introduced Jan. 1, 2007, by the employer Pitney Bowes. The company reduced copayments for statins for patients being treated for vascular disease or diabetes and for clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis) for all patients prescribed the medication.

They identified 2,830 patients (2,051 statin users and 779 clopidogrel users) who received prescriptions between Jan. 1, 2006 and Dec. 31, 2007, and who were eligible for copayment reductions. For a control, they included 49,801 patients (38,174 statin users and 11,627 clopidogrel users) enrolled in standard insurance plans.

Mean monthly patient costs dropped steeply in the reduced copayment groups while costs edged up in the control groups. The increase in the monthly rate of adherence totaled 7.1 percentage points among statin users and 5.9 percentage points among clopidogrel users compared with the control groups. Beneficiaries of the new policy had lower rates of physician visits, hospitalizations and emergency department admissions but not of major coronary events or coronary revascularization.

The insurer’s combined pharmacy and medical spending rose in the reduced copayment group but the patients’ costs for out-of-pocket drugs and other medical services dropped, making overall costs unchanged.

“Using formal econometric techniques applied to real-world data in the present study, we observed reductions in resource use,” Choudhry et al wrote. “In light of the results of MI FREEE, the magnitude of the changes we observed would plausibly be expected from the previously reported modest but significant improvements in adherence resulting from this policy. However, we found that these beneficial changes were not associated with an increase or a decrease in combined patient and insurer spending or clinical event rates.”

They suggested that the clinical benefit of medication use in these lower risk patients may not have become apparent within the study timeframe; that lower-risk patients may derive less benefit from drugs such as clopidogrel; or that, as in MI FREEE, the lack of clinical benefit may be attributed to no differences in revascularization rates between the two patient groups. Limitations to the study included a modest sample size, the potential for utilization trends that the study didn’t capture and the potential for unmeasured differences between the patient groups.

Nonetheless, the study demonstrated other benefits, including a 35 percent and 28 percent reduction in out-of-pocket payments by patients for statins and clopidogrel, respectively. Based on their findings, copayment reductions may be applicable in a wide range of for cardiovascular medications and other at-risk patient groups, Choudhry et al suggested.  

“Our finding that reducing copayments for statins and clopidogrel was cost neutral in the first 12 months of the policy's implementation should be reassuring and may be a sufficiently attractive outcome to promote the greater use of this strategy, especially given that there are few, if any, quality improvement interventions that actually reduce health spending,” the authors wrote.