Cutting Copays for Post-MI Drugs Helps Outcomes

Reed Miller

November 14, 2011

November 14, 2011 (Orlando, Florida) — Making post-MI patients copay for their essential medications is penny wise and pound foolish for insurance companies, a new study shows [1].

"For essential medications--the meds we're talking about are highly evidence-based, we don't want people to stop using those meds when the copays are a relatively small part of cost relative to costs of hospitalizations, or even death, that result from not using the drugs," study lead author Dr Niteesh Choudhry (Harvard University, Boston, MA) told heartwire . Choudhry presented results of the 5855-patient Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial this morning at the American Heart Association 2011 Scientific Sessions. Results of the study are simultaneously published in the New England Journal of Medicine.

The study shows that patients who had suffered an MI were significantly less likely to have another major cardiac event (MI, angina, heart failure, or stroke) if the costs of statins, beta blockers, ACE inhibitors, and angiotensin-receptor blockers were totally covered by insurance rather than if their insurance company charged them a copay for their drugs (11 per 100 person-years vs 12.8 per 100 person-years; p=0.03). For the primary outcome of revascularization plus major cardiac events combined, the difference was not statistically significant (17.6 per 100 person-years vs 18.8 per 100 person-years; p=0.21).

The patients with no copay paid 26% less overall for their drugs than the patients with copays. Over the three years of follow-up, the people with no copay actually cost the insurance company slightly less to care for than the people with one ($66 008 vs $71 778; p=0.68).

Not only does eliminating copays not cost the insurance company more in the long run, it's also an easy change to implement, Choudhry said. "Insurers that want to do this could do this tomorrow. It literally just means changing pharmacy authorization codes. It doesn't mean deploying armies of nurse health coaches or anything like that."

Today, Aetna, the insurance company that sponsored the trial, introduced its Aetna Rx Healthy Outcomes program, which will reduce or eliminate copays for targeted prescription drugs for MI patients while advising patients on how to take the drugs and manage any side effects [2].

Still a Lot of Adherence Problems to Sort Out

Although the study is positive overall, it reveals that cost is not the only barrier to better patient adherence to post-MI drug regimens. For each of the drugs, the average adherence rate for patients with copays was 35.9% vs 49% for the no-copay group--a significant difference--but the absolute rates were still dissatisfying, and only about 10% of patients with no copays were on all of the drugs one year after starting the regimen. In an accompanying editorial [3] Dr Lee Goldman (Columbia University, New York, NY) and Dr Arnold Epstein (Harvard University, Boston, MA) agree that "perhaps the most sobering findings were both the low baseline adherence and the small improvements in adherence in what should have been a highly motivated group of patients."

Copays are one of the tools insurance companies use to discourage overutilization of therapies, but "patients are often poor judges of absolute or relative benefits of different health services, [and] reducing or eliminating the costs of highly beneficial medicines is almost certainly one key component of increasing adherence, even if its absolute benefit is distressingly modest."

Choudhry told heartwire that a number of challenges to better patient adherence remain and that each of them must be addressed one by one in each patient. "You may have five reasons to be nonadherent to prescribed drugs and I may have five reasons to be nonadherent to the same prescribed drugs, so both of us not only have more than one reason, but our reasons might not be the same," he said. The magnitude of benefits for any one effort to improve adherence has been relatively modest, he said.

Some ideas for improving patient adherence include improving convenience of access and reducing the complexity of the drug regimen and electronic reminder systems. "Think of about your typical heart patient, who has five to 10 different medications, probably written by a combination of a primary-care doctor and a cardiologist and maybe another one or two doctors, and they go to the pharmacy to pick up multiple drugs on multiple visits. That burden of access drives nonadherence."

Also, patients must be educated about the drugs' expected benefits, he said. "People may not understand why they're taking them or not understand, for example, that they're not supposed to feel better on their statins. It's just supposed to lower their cholesterol."

Commenting on the study at the conference, Dr Eric Peterson (Duke University, Durham, NC) agreed that adherence to post-MI medication is "miserable," and so investigation of "value-based" programs, like the one tested, in this study is vital.

He suggested that the study showed only a relatively small benefit of eliminating copays because the trial was slightly underpowered and the study population was relatively young and healthy, so event rates were low. Nevertheless, "widespread adoption [of this strategy] can be recommended, in my view," Peterson said. "It improved outcomes on total vascular events, and the program essentially paid for itself. Adherence in this country remains a huge problem in post-MI secondary prevention."

Choudhry reports receiving consulting fees from Mercer Health and Benefits and grant support from CVS Caremark. Disclosures for the coauthors are listed in the paper. Goldman is an associate editor for the New England Journal of Medicine.

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