MI FREEE puts post-MI savings from full drug coverage at $2B

Giving full prescription drug coverage to patients in the U.S. who experienced a first MI could save almost $2 billion annually over their lifetime, an analysis of MI FREEE found. Although only one carrier served patients in the trial, the results could apply to other payers as well, the lead researcher said.

“It should be very generalizable to, at the very least, a broad selection of commercially insured patients with acute coronary syndrome,” said Niteesh K. Choudhry, MD, PhD, executive director of the Center for Healthcare Delivery Sciences at Brigham and Women’s Hospital in Boston and lead author of the paper published online May 5 in Circulation: Cardiovascular Quality and Outcomes.

MI FREEE (Post Myocardial Infarction Free Rx Event and Economic Evaluation) was a pragmatic cluster-randomized policy trial that evaluated whether removing financial barriers to evidence-based therapies improved adherence and outcomes in patients after an MI. It also looked at costs. The primary outcome was a first major vascular event or revascularization.

The study randomized patients covered under Aetna to receive full coverage or shoulder monthly copays for statins, beta-blockers, ACE inhibitors and ARBs. After a median follow-up of 394 days, adherence was higher in the full coverage group by 4 to 6 percentage points compared with the standard coverage group. The rates of a first major vascular event and total major vascularization or revascularization were lower with full coverage, but there was no difference between groups in the primary outcome.

Expenditures in the fully covered group were $66,008 vs. $71,778 with standard coverage, and patients in the fully covered group paid 26 percent less in overall out-of-pocket costs compared with the control group.

In the most recent analysis, Choudhry and colleagues used a Markov model to explore the cost-effectiveness of full coverage over a long term. The model assumed the benefit of full coverage that was demonstrated in MI FREEE remained constant for five years, decreased over the next five years and then provided no added benefit but continued cost for the rest of the patient’s lifetime.

“When we do these kinds of analyses we set up the models to be purposefully conservative,” he said. “We certainly don’t want to oversell a result; our goal is to get the truth. Even when we stacked the deck, these are the results we get.”   

They found that patients with full coverage had 9.6 quality-adjusted life years (QALY) and lifetime costs of $167,401 vs. 9.46 QALY and lifetime costs of $171,412 with standard coverage. Applying the cost reduction of $4,011 to the annual number of Americans expected to have a first MI totaled $2 billion over the patient’s lifetime.

Even in sensitivity analyses that put full payment through the wringer, it remained cost-effective, meeting a willingness to pay threshold of $100,000 in 88 percent of cases.

One challenge with this approach is that the insurer incurs immediate costs for a benefit that it may never see if the patient later changes carriers or transitions to Medicare. Choudhry pointed out that based on MI FREEE results, Aetna recognized that even the short-term cost saving made a full payment model worthwhile and initiated a program.

“You can make a business case in the short run,” he said.

The average age in MI FREEE was 54, but the patients otherwise had a similar demographic profile to traditional MI patient cohorts, Choudhry said. “Making the case for Medicare may be a little bit different,” he agreed. Cost of care for older patients may be higher but their event rates are higher, too, “so the benefit may be greater. Those two things probably trade off each other.”  

Still, once patients are old enough to enter Medicare, they remain a beneficiary for life. “If there is any payer that has an incentive, it is Medicare,” he said.