If you want to understand why so many people are ditching newspapers and moving to the Internet for news look no further than today’s editorial in the NY Times called “when co-pay gets in the way of health”. The editorial suggests that offering zero co-pay on medications that are proven effective could be a way to increase compliance thus lowering healthcare costs. What the author fails to take into consideration is the fact that most of the “proven” medications are already generic and that co-pay fees go to pharmacy operational costs not insurers or drug companies. In addition costs is just one of the variables for non-compliance.
According to the Times The New England Healthcare Institute has estimated that solving non-adherence could save $290 billion a year, or 13 percent of total annual medical spending in the United States. A num- ber this large is surely open to quibbling, but divide it by 10 and it is still a large figure.
Consider a patient recovering from a heart attack. A small cocktail of drugs may cost a trivial amount — say, $5 — yet it reduces the risk of subsequent heart disease mortality by as much as 80 percent. That’s a good deal, but as many as 50 percent of people fail to take these medications regularly.
People are not overusing inef- fective drugs; they are underusing highly effective ones.
All co-pays should depend on measured medical value; high co-pays should be reserved for drugs and medical services that have little proven value. Second, some people will neglect to take their medications even if co-pays are zero. This proved true even in the Choudhry study.
The Choudhry study
A recent experiment by a team led by Niteesh Choudhry, a professor of medicine at Harvard, quantifies the problem. The experiment involved nearly 6,000 patients who had just suffered a heart attack, and were prescribed drugs known to reduce the chance of another one — statins, beta-blockers, angiotensin-converting-enzyme inhibitors or an- giotensin-receptor blockers. Half had their co-pays for these drugs waived; the other half paid the usual fee. As expected, more people in the zero co-pay group took the drugs, and their health im- proved. Those in the zero co-pay group were 31 percent less likely to have a stroke, 11 percent less likely to have another major “vascular episode” and 16 percent less likely to have a myocardial infarction or unstable angina. None of these benefits came at a net monetary cost. The insurers did not spend more in total. By some measures, they spent less.
Some people will neglect to take their medications even if co-pays are zero. This proved true even in the Choudhry study.
This is an example of a great book learning experiment but fails, in my opinion, to look at real life and challenges of dispensing and marketing drugs. Even people who need medications to stay alive are not always compliant. A 2009 study showed about 25% of patients being treated with imatinib (Gleevec, Novartis) for chronic myeloid leukemia (CML) did not take the drug as prescribed, and ended up taking less than 90% of their imatinib doses. Interviews with patients revealed a variety of reasons for nonadherence, but one of the most common was hoping to minimize adverse effects. One patient said that he stopped taking the drug when he went on holiday because he wanted to enjoy himself and felt he had more energy when he was not taking the drug, she said.
I’m not saying that there should not be a lower or zero co-pay for some drugs, what I am saying is that to suggest that this is the answer for non-compliance is foolish. What is needed to increase compliance is a multi-behavioral approach that involves patients, insurers and drug companies.