Out-of-pocket costs of brand-name drugs remain high for people with chronic conditions
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Health care costs remained high for Medicare beneficiaries with common chronic conditions for which brand-name medications without generic alternatives were recommended, according to findings published in JAMA Internal Medicine.
“High out-of-pocket costs may reduce medication adherence and limit the benefit of guideline-recommended treatment while increasing the burden of treatment among patients with multiple chronic conditions,” Tianna Zhou, BS, a medical student at the Yale School of Medicine, and colleagues wrote.
Zhou and colleagues conducted a retrospective cross-sectional study of 2009 and 2019 Medicare prescription drug plan (PDP) information to estimate the annual, inflation-adjusted out-of-pocket costs for hypothetical older patients with at least one of eight common chronic disease who adhered to guideline-recommended therapy. The chronic conditions included in the analysis were atrial fibrillation, COPD, heart failure with reduced ejection fraction (HFrEF), hypercholesterolemia, hypertension, osteoarthritis, osteoporosis and type 2 diabetes.
Overall, the researchers analyzed 3,599 Medicare PDPs from 2009, of which 1,998 were Medicare Advantage plans and 1,601 were stand-alone plans, as well as 3,618 Medicare PDPs from 2019, of which 2,719 were Medicare Advantage plans and 899 were stand-alone plans.
In total, 15 drug classes were recommended at least once in clinical practice guidelines for the chronic conditions, amounting to 47 medications in 2009 and 58 in 2019.
Costs for patients with a single condition
For patients with one condition enrolled in any PDP, median annual costs decreased from 2009 to 2019 for six of the eight conditions analyzed, including COPD (from $1,218 to $845), HFrEF (from $268 to $103 when treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, an evidence-based beta blocker and an aldosterone antagonist), hypercholesterolemia (from $128 to $36), hypertension (from $141 to $48), osteoarthritis (from $96 to $48) and osteoporosis (from $128 to $32).
However, the median cost for people with atrial fibrillation increased from $91 to $1,579, as did the cost for people with type 2 diabetes, from $172 to $992, and for those with HFrEF who were treated with an angiotensin receptor neprilysin inhibitor (sacubitril-valsartan), an evidence-based beta blocker and an aldosterone antagonist, from $268 to $1,018, according to Zhou and colleagues.
During the study period, the percent change in median out-of-pocket costs ranged from 75% for osteoporosis to 1,634% for atrial fibrillation.
Costs for patients with multiple conditions
For an older adult enrolled in any PDP with a cluster of five commonly comorbid conditions (COPD, hypertension, osteoarthritis, osteoporosis and type 2 diabetes), the researchers found that the median out-of-pocket cost in 2019 was $1,999, a 12% decrease from $2,284 in 2009. Yet, for an older adult enrolled in any PDP with all eight chronic conditions, the median cost in 2019 was $3,630, a 41% increase from $2,571 in 2009.
Stand-alone vs. Medicare Advantage PDPs
Stand-alone PDPs cost more than Medicare Advantage PDPs for the management of all single conditions in 2009, whereas stand-alone PDPs cost more than Medicare Advantage PDPs only for the management of atrial fibrillation in 2019, according to the researchers.
Overall, when adjusting for inflation, median annual costs for guideline-recommended medications for older adults with multiple chronic conditions generally decreased from 2009 to 2019.
“However, among those conditions for which brand-name drugs without generic versions became guideline recommended, out-of-pocket costs increased substantially between 2009 and 2019,” Zhou and colleagues wrote. “These findings suggest that not all older adults experience equal burdens associated with out-of-pocket medication costs.”
Provider advocacy
In a related commentary, Robert J. Besaw, MPH, a graduate student, and Stacie B. Dusetzina, PhD, an associate professor of health policy and an Ingram associate professor of cancer research, both at Vanderbilt University Medical Center, said that in recent years, Congress has received multiple proposals for limiting out-of-pocket costs. However, considering the prevalence of chronic conditions and the burden of health care costs, “it is worthwhile for physicians to consider whether there are lower cost treatment options available to their patients,” when feasible, they wrote.
“Ultimately, there is a need for both cost-conscious prescribing by physicians and redesign of Medicare benefits to better support beneficiaries’ access to needed drugs,” Besaw and Dusetzina wrote.
References:
Besaw RJ, Dusetzina SB. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.7454.
Zhou T, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.7457.
Perspective
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Margot Savoy, MD, MPH, FAAFP
Most family physicians will find this article confirms their daily experience caring for patients living with chronic medical conditions. While advances in medicine and technology are certainly a societal win, as the authors adeptly point out, these advances often come with some significant financial costs. At the close of our visit, a patient told me she isn’t sure she can afford to get old, and I worry she may be right. We can’t forget that medication only represents a portion of the total costs associated with aging with chronic medical conditions in the U.S.No family physician enjoys struggling with whether to give patients the best advice vs. the best advice the patient can afford. When guidelines are unclear about the true magnitude of the benefit of choosing one medication over another, it is difficult to know which recommendations we can consider being more flexible about. Trying to balance convenience, quality of life, cost and effectiveness while staying within the lowest tier of their ever-changing formulary isn’t a job for the faint-hearted. If the patient cannot afford the prescribed optimal medication, they often end up taking nothing at all. As another patient shared with me, he juggles medications based on what he can afford today by deciding whether his diabetes or his COPD was going to kill him first.
It is concerning that we continue to lack a consistent way to assist patients as they choose insurance coverage. Most of your life, these decisions are limited and tied to employment. We should not expect individuals to simply know how to find and interpret the data needed to make such a critical decision alone. Perhaps now would be a good time to reinvest in the patient navigators who were instrumental during the early days of the Affordable Care Act, so everyone has an equal opportunity to be covered by optimal insurance options based on their situation and needs.
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