Generic Lipid Lowering Drug Adherence Proposal Program Overview
Medication nonadherence in chronic conditions is a recognized public health problem. Some studies estimate that the overall cost of non-compliance could be as high as $100 billion if factors such as the cost of readmission to hospitals and nursing homes, of lost productivity and of new prescriptions are considered. Rates of nonadherence with any medication treatment average at an estimated rate of 50%. For example, as many as 65% of dyslipidemics don’t fill their first prescription and approximately half of patients receiving lipid lowering therapy will discontinue their medication within 6 months of starting therapy. Initial studies have shown that patient health will benefit from initiatives that support greater adherence, and healthcare costs may be saved. The State Health Plan proposes to provide coverage of generic lipid lowering medications for $4 copay, which will provide a low cost prescription option for members with high cholesterol. Studies show that these medicines – known as statins – significantly reduce the risk of heart attack and stroke for patients with high cholesterol. This program will promote the use of generic medications in this category of medications which currently has an annual spend of $54 million (only $18 million on generics with $36 million spent on brands) and will aim to increase medication adherence with the goal of decreasing long term medical costs for these members. This proposed program is similar to other health plan (BCBSNC, Humana, Aetna) sponsored value based benefit programs which offer lower cost generics for chronic diseases aiming to decrease long term medical costs. The Plan is focusing on only one class of medications for this pilot due to its limited financial liability. The proposal is to offer coverage of generic lipid lowering medications for $4 copay beginning July 1, 2009 for at least 18 months and evaluate the generic dispensing rate (GDR) and medication adherence. An initial analysis will be done at 12 months. The program may need to run longer to see any results on adherence. The Plan’s current lipid lowering medication adherence is approximately 70% compared to benchmarks from other similar government plans at 73-75%.
Financial Impact and Cost Savings
Approximately 20% of State Health Plan members use a lipid lowering medication. Providing coverage of generic lipid lowering medications for $4 copay will provide a low cost therapy option for members saving them $72 annually if they are currently taking a generic medication or $312 annually if the member switches from a preferred brand name medication to a generic alternative. Since most of the members requiring lipid lowering therapy are on multiple chronic medications that may have rising copays, this savings will hopefully assist financially in enabling increased adherence. The long term medical savings from increased adherence is very difficult to calculate at this point. The Plan’s current GDR in this drug class is 34%. It is estimated that for every 1% increase in GDR the savings would be approximately $500,000. Based on this calculation, an increase of at least 3.8% in the GDR would be needed to break even with the loss in copay revenue. With the currently very low GDR in this drug class that is certainly achievable. Category Current GDR Plan cost increase due to $4 copay (1 year) GDR change to make up loss Potential savings after copay change and increase in generic use by 5% $500,000
All generic lipid-lowering medications
34%
$1,910,874
3.8
Medical Evidence
Medical studies have proven that increased prescription cost sharing is highly correlated with decreased prescription utilization; however the long-term consequences of these benefit changes on overall health costs is uncertain.1 Also, studies show that decreased member cost share improves chronic medication adherence; however, it has not been proven if this increased adherence is clinically significant and sustainable. It is speculated that increased adherence provides long term medical results; however, the return on investment is elusive. One retrospective study has shown that for diabetes and high cholesterol, increased medication adherence is associated with lower disease-related medical costs including hospitalizations.2 In this study increased medication costs were offset by medical reductions. The return on investment for a 20% increase in drug utilization for hypercholesterolemia was estimated to be 5.1:1 in this study.
Nonadherence and discontinuation rates were compared in a group of patients taking statins for prevention of coronary heart disease. In this study, the more patients were charged for their medications, the earlier they stopped treatment. The time it took for 50% of patients to abandon therapy averaged 3.9 years among patients paying <$10, 2.2 years among those paying between $10-$20, and 1 year among those paying >$20. 3 In a recent Medco Medicare population study, they showed that during 2007, the rate of patients who suspended generic statin treatment was 20% lower than those on a brand-name medication. This validates the positive impact generics have on patient compliance.4 Two studies from Prime Therapeutics involving statins and antihypertensives, showed that pharmacy benefit designs encouraging the use of low-cost generics can have a significant impact on keeping members on their medications. The studies found that decreased member costs were associated with a significant improvement in medication-use persistency, measured by prescription refills, over a 6 month duration. The antihypertensive study found that pharmacy patients paying $1 copays remained on their drugs 21% longer than those paying $25. The results of the statin study demonstrated comparable findings.5 In general, Plans are awaiting definitive studies to prove that decreased cost share improves adherence and long term medical costs. Results on medical cost savings from a University of Michigan study on lower cost diabetes medications is due out in October. It is the Plan’s goal to monitor the results of our proposed pilot program and to provide evidence for our Plan as well as others whether to offer lower cost generics for chronic diseases as a standard benefit.
References
1
Goldman DP, et al. Prescription Drug Cost Sharing. Associations with Medication and Medical Utilization and Spending and Health. JAMA. 2007;298:61-69.
Sokol MC, et al. Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care. 2005;43:521-530.
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Ellis JJ, et al. Suboptimal Statin Adherence and Discontinuation in Primary and Secondary Prevention Populations. J Gen Intern Med. 2004;19:638-645.
Medco press release 10/13/08. US Medicare Coverage Gap Leads to Drop in Drug Therapy for Cholesterol Patients. Prime Therapeutics press release 11/27/06. Low Copay Generics Improve Medication-Use over 20 percent.
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