Higher Copays Delay the Initiation of Therapy

Requirement of higher copayments for prescription drugs can delay the start of treatment for patients with newly diagnosed chronic problems, such as hypertension, hypercholesterolemia, and diabetes. This finding is particularly salient in patients who have no prior experience with prescription drugs. These results were reported by Solomon and coworkers,1 who measured the time un- til initiation of prescription drug therapy in 17,183 patients with newly diagnosed hypertension, hypercholesterolemia, or diabetes. The patients had employer-provided drug coverage from 31 different health plans, and the average patient age was about 75 years. The study was conducted from 1997 to 2002. The investigators found that higher copays were associated with delayed initiation of treatment. For example, in survival models, doubling copays resulted in a significant decrease in the predicted percentage of patients starting therapy for hypertension, from 54.8% to 39.9% at 1 year after diagnosis and from 81.6% to 66.2% at 5 years after diagnosis (Table). Similar significant patterns were observed for patients with hypercholesterolemia and patients with diabetes. In addition, treatment initiation and the effect of copays depended on the patients’ prior experience with prescription drugs. Patients who had not previously taken prescription drugs started treatment later and were much more sensitive to the burden of higher copays. More Evidence That Treatment Adherence Reduces Health Care Costs Adherence to therapy has been associated with improved patient outcomes and reduced health care costs in a number of clinical settings. Esposito and colleagues2 at Mathematica Policy Research, Inc, in Princeton, NJ, recently reported that adherence is associated with lower health care costs in patients with congestive heart failure (CHF). They analyzed Medicare and Medicaid data from 4 states and used the medication possession ratio to assess adherence to therapy in patients with CHF. Compared with beneficiaries who were nonadherent to therapy, those who were adherent were significantly less likely to be hospitalized, had fewer hospitalizations, and had shorter hospital stays (about 2 fewer inpatient days). In addition, the adherent patients were less likely to have an emergency department (ED) visit and had fewer ED visits. The study also found that total health care costs for adherent patients were $5910 (23%) less per year than for nonadherent patients. There was a graded relationship between adherence and health care costs, and the relationship was more pronounced when beneficiaries were divided into subgroups. Early Cessation of Antidepressants Linked to Increased Health Care Costs in the Elderly A study conducted in Quebec has documented that older patients often stop taking antidepressants early in the course of their treatment, and this early discontinuation of therapy is associated with increased health care costs. Tournier and associates3 retrospectively studied 12,825 elderly outpatients who started antidepressant therapy. The rate of “nonper- sistence”-defined as a duration of therapy shorter than 180 days-was 55.6%. Products associated with low antidepressant costs were frequently associated with high costs of other medications and health care services. The lowest rate of nonpersistence was found for paroxetine. The most favorable incremental cost/ persistence ratio was found for fluoxetine. The authors say that intervention programs directed at improving treatment persistence would result in better use of health care resources and would reduce costs. Comparing Pneumonia-Related Costs Across Different Managed Care Plans Community-acquired pneumonia (CAP) is associated with higher total payments for patients who are enrolled in PPO plans than for enrollees in other plans, according to a study by Landsman and coworkers.4 The higher payments were mostly attributable to increased resource use among patients with the least severe illness. They analyzed health care use and total payments associated with CAP among enrollees in 5 employer-provided plans (fee-for-service, PPO, point of service, partial capitation, and HMO). The patients with CAP who were enrollees in PPO plans were older and had more severe episodes, more office visits, a higher rate of hospitalization, a longer duration of hospitalization, and a higher inpatient mortality rate than did enrollees of other managed care plans. When the analysis controlled for age, sex, disease severity, and location, total payments were higher for those patients with PPO plans; this finding was mostly attributable to a greater number of office visits and longer hospital stays. References: References 1. Solomon MD, Goldman DP, Joyce GF, Escarce JJ. Cost sharing and the initiation of drug therapy for the chronically ill. Arch Intern Med. 2009;169:740-748. 2. Esposito D, Bagchi AD, Verdier JM, et al. Medicaid beneficia- ries with congestive heart failure: association of medication adherence with healthcare use and costs. Am J Manag Care. 2009; 15:437-445. 3. Tournier M, Moride Y, Crott R, et al. Economic impact of non-persistence to antidepressant therapy in the Quebec community-dwelling elderly population. J Affect Disord. 2009;115:160-166. 4. Landsman PB, Smith DG, Fendrick AM. Healthcare utilization in community-acquired pneumonia episodes of care: a comparison across the continuum of managed care. Med Care. 2009 Jul 30; [Epub ahead of print].