Written by Rafael Fonseca MD and Robert Goldberg PhD
Two recent articles in the NEJM (1) e) and Annals of Internal Medicine (2) propose that restrictions or eliminations of co-pay assistance programs by pharmaceutical companies are needed since they distort the market and therefore, while few benefit, many suffer in the form of higher healthcare expenditures. They are factually correct but the conclusions point to a larger problem; the third party payer system in health care. When consumers (in this case patients) are detached from the price consequence of transactions they will be less careful in their selections. However, the proposal presented in these articles are, at least in the short-term, patient unfriendly and immediate implementation of their recommendations would limit, severely, access; particularly for patients with serious or life-threatening conditions. The Annals article is notorious in that it fails to mention the increased cost-sharing pressure that patients are facing from the payers.
So what are the solutions? Ideally, healthcare should be divided between the routine care and the catastrophic care. Routine care should involve much more “skin in the game.” In my view, regular care should not be covered under traditional heath insurance but be bought directly, with compassionate support tools for those in need. In this type of care I could envision more direct pressure in the selection of older medications for which many alternative exist. There are many options for anti-hypertensive medications, statins, etc. In the absence of a third party payer system the Epipen would never cost $600. This is where consumer pressure, with co-pay requirement as a discriminator, should be employed; vigorously, if you may. I would not disagree that if an equivalent generic exists, a true equivalent, then having the patient paying more for a branded product is fine. This is not to say that branded products and generics are always the same. Sometimes production quality may suffer or sometimes an alternative may not be the same as the original, similar and yet not the same product. But if you want the branded statin maybe you should pay a bit more. Who could argue with that?
However, for more expensive medications, medications used for serious, chronic severe or catastrophic illnesses the pressure seems misguided. For instance preventing co-pay assistance for patients with cancer seems inhumane. Dusetzina and colleagues have documented that lack of supplemental insurance delays initiation of treatment for CML (3). Should we disincentivize the use of medications that can be lifesaving for a cancer patient so they consider inferior treatments? Should we place additional burdens in someone who is at high risk for bankruptcy? Someone who cannot work or whose caregiver cannot work? That seems inappropriate. Furthermore, for many of these newer and expensive medications there are no suitable alternatives (4). Dr. Bach and colleagues were able to reduce the price of a competing monoclonal antibody, but that is a rarity in oncology and more of an exception. Should myeloma patients forgo lenalidomide in favor or thalidomide and face certain peripheral neuropathy? Or should a diabetic myeloma patient be forced to be treated with bortezomib instead of carfilzomib and again face neuropathy? To create a disincentive as this for people facing serious medical illness appears to me as a fundamental violation of medicine’s stance of benevolence. Rather this has the appeal of altruism, sacrifice the few for the benefit of the many.
Lastly, government regulations that eliminate this co-pay assistance are demonstrably patient unfriendly. Commercially insured patients can receive this directly and in another study by Dusetzina she shows that the average co-pay for specialty medications is only $35 (5). In another study it was shown that 90% of myeloma patients pay less than $100 per month for lenalidomide, a backbone for the treatment of this disease. In the meantime, Medicare beneficiaries struggle to find indirect support with funds provided by the pharmaceutical companies to third parties. I’ve written about this topic before, but again is a built-in disincentive to lessen the use of medications (6). What if these medications save dollars by preventing hospitalizations and decreasing expenses elsewhere? Once again it is pound foolish to only concentrate on the price of drugs.
1. Dafny LS, Ody CJ, Schmitt MA. Undermining Value-Based Purchasing - Lessons from the Pharmaceutical Industry. The New England journal of medicine. 2016. Epub 2016/10/13. doi: 10.1056/NEJMp1607378. PubMed PMID: 27732125.
2. Ubel PA, Bach PB. Copay Assistance for Expensive Drugs: A Helping Hand That Raises Costs. Annals of internal medicine. 2016. Epub 2016/10/11. doi: 10.7326/M16-1334. PubMed PMID: 27723893.
3. Winn A, Keating N, Dusetzina S. Factors Associated With Tyrosine Kinase Inhibitor Initiation and Adherence Among Medicare Beneficiaries With Chronic Myeloid Leukemia. Journal of Clinical Oncology. 2016;10.1200/JCO.2016.67.4184.
4. Fonseca R. 2016. Available from: https://tmblr.co/Z0_1wo2CgPnw1.
5. Dusetzina SB. Share Of Specialty Drugs In Commercial Plans Nearly Quadrupled, 2003-14. Health Aff (Millwood). 2016;35(7):1241-6. Epub 2016/07/08. doi: 10.1377/hlthaff.2015.1657. PubMed PMID: 27385240.
6. Fonseca R. 2016. Available from: https://tmblr.co/Z0_1wo2D7lHbj.