Niteesh K. Choudhry, M.D., Ph.D., Jerry Avorn, M.D., Robert J. Glynn, Sc.D., Ph.D., Elliott M. Antman, M.D., Sebastian Schneeweiss, M.D., Sc.D., Michele Toscano, M.S., Lonny Reisman, M.D., Joaquim Fernandes, M.S., Claire Spettell, Ph.D., Joy L. Lee, M.S., Raisa Levin, M.S., Troyen Brennan, M.D., J.D., M.P.H., and William H. Shrank, M.D., M.S.H.S.
N. K. Choudhry, J. Avorn, R. J. Glynn et al., "Full Coverage for Preventive Medications After Myocardial Infarction," New England Journal of Medicine, published online Nov. 14, 2011.
Heart attack patients discharged from the hospital were more likely to take prescription medications for their condition when copayments were eliminated, compared with patients who had copayments. Patients who had their copayments waived also experienced fewer heart attacks, strokes, and other vascular events over the course of the study period. The trial reduced patients' out-of-pocket spending and did not significantly change total spending by insurers.
The cost of prescription drugs is a major contributing factor to medication underuse. According to research published in Health Affairs, one-third of Americans do not fill a prescription, or reduce the prescribed dose, because of out-of-pocket costs. Eliminating such costs may encourage people to use medication appropriately and ultimately help them stay healthier. In this Commonwealth Fund–supported study, researchers assigned patients who had been discharged from the hospital after heart attack to two groups: those with no cost-sharing or copayments for routinely prescribed drugs, such as statins, angiotensin-converting enzyme (ACE) inhibitors, and beta blockers (i.e., the full-coverage group) and those with traditional pharmacy benefits that require copayments (i.e., the usual-coverage group).
The elimination of copayments reduced patients' financial burdens, did not change overall spending, and may have provided clinical benefits. This is "a rarity in health care," the authors write, "and suggests that eliminating cost-sharing for secondary prevention after myocardial infarction may be cost-effective." Still, overall adherence rates in the study remained low. Even in the full-coverage group, less than half of patients were fully adherent with their prescribed therapies. Interventions to address other factors that contribute to nonadherence—such as education about prescriptions, attitudes, and the complexity of prescribed regimens—are likely necessary.
Patients were deemed eligible for this study if they received both medical and prescription drug benefits through Aetna and if they had been discharged from the hospital with a diagnosis of acute myocardial infarction. The final sample included 5,855 patients who were randomly assigned to a full-coverage group, in which they had no cost-sharing for statins, ACE inhibitors, and beta blockers, or to a usual-coverage group, in which they had traditional pharmacy benefits. The researchers compared rates of medication adherence, health outcomes, and health spending for the two groups.
Eliminating copayments for evidence-based medications can improve adherence to treatment, decrease patient spending without increasing overall health costs, and improve health outcomes.