to medications that are
prescribed after myocardial infarction is poor. Eliminating out-of-pocket costs
may increase adherence and improve outcomes.
enrolled patients discharged
after myocardial infarction and randomly assigned their insurance-plan sponsors
to full prescription coverage (1494 plan sponsors with 2845 patients) or usual
prescription coverage (1486 plan sponsors with 3010 patients) for all statins, beta-blockers,
angiotensin-converting–enzyme inhibitors, or angiotensin-receptor blockers [blood pressure meds].
The primary outcome was the first major vascular event or revascularization.
Secondary outcomes were rates of medication adherence, total major vascular
events or revascularization, the first major vascular event, and health
Rates of adherence ranged from 35.9 to 49.0% in the usual-coverage group and were 4 to 6 percentage
points higher in the full-coverage group (P<0.001 for all comparisons).
There was no significant between-group difference in the primary outcome (17.6
per 100 person-years in the full-coverage group vs. 18.8 in the usual-coverage
group; hazard ratio, 0.93; 95% confidence interval [CI], 0.82 to 1.04; P=0.21).
The rates of total major vascular events or
revascularization were significantly reduced in the full-coverage group
(21.5 vs. 23.3; hazard ratio, 0.89; 95% CI, 0.90 to 0.99; P=0.03), as was the
rate of the first major vascular event (11.0 vs. 12.8; hazard ratio, 0.86; 95%
CI, 0.74 to 0.99; P=0.03).* The elimination of copayments did not increase
total spending ($66,008 for the
full-coverage group and $71,778*** for the usual-coverage group; relative
spending, 0.89; 95% CI, 0.50 to 1.56; P=0.68). Patient costs were reduced for
drugs and other services (relative spending, 0.74; 95% CI, 0.68 to 0.80;
elimination of copayments for
drugs prescribed after myocardial infarction did not significantly reduce rates
of the trial's primary outcome. Enhanced prescription coverage improved
medication adherence and rates of first major vascular events and decreased
patient spending without increasing overall health costs. (Funded by Aetna and
the Commonwealth Fund; MI FREEE ClinicalTrials.gov number, NCT00566774.)
by unrestricted research
grants from Aetna and the Commonwealth Fund to Brigham and Women's Hospital.
Choudhry reports receiving
consulting fees from Mercer Health and Benefits and grant support from CVS
Caremark; Dr. Glynn, receiving consulting and lecture fees from Merck and grant
support from AstraZeneca and Novartis; Dr. Schneeweiss, receiving consulting
fees from WHISCON and grant support from Pfizer and Novartis; Ms. Toscano, Dr.
Reisman, Mr. Fernandes, and Dr. Spettell, being employees of and having an
equity interest in Aetna; Dr. Brennan, being an employee of, having an equity
interest in, and receiving board membership fees from CVS Caremark; and Dr.
Shrank, receiving consulting fees from United Healthcare and grant support from
CVS Caremark and Express Scripts.
estimate of cost is not possible given the sketchy information provided. But
assuming that the rate of compliance was an
average of the 35.9 and 49% compliance for the 3 drugs, and that the cost of
each are about the same, then the average compliance for a drug was 42.45% or
that 57. 55% of the time the drugs weren’t taken. Secondly assuming that
the drug costs were an
average of $68,893. Assuming 100%
compliance 1.5755 ($68,893) = $108,541 rounded off to $109,000 per year for full
**this is double talk.
Not only are the standard not brought out, for major vascular events
(which is obvious something other than MI), and this is paired with
revascularization. Thus the 4% higher
compliance group has paired a good thing increasing blood flow (possible to the
heart muscle) is paired with an adverse event, “vascular events”. The
normal pattern would be two good things
such as fewer MIs and fewer strokes; not a good and bad event.
*** Why aren’t the total
costs of the drugs the same for
both groups? Note that those with copay
are charged more than those with full coverage.
The copay group is charged $5,570 more which 8.74%. This is reason to
expect a kick-back to the
participating parties taken from the extra which of those who have a copay.
“Now, with help from the
dissemination of quality metrics,
cost-saving medications such as beta-blockers, aspirin,
angiotensin-converting–enzyme (ACE) inhibitors are nearly universally
prescribed to eligible patients after myocardial infarction,2,3” from another article in the same
NEJM. One reason for giving aspirin
besides that it works, is that if there is a stomach bleed, aspirin is
blamed. At the low dose of under 100 mg,
it doesn’t cause stomach bleeds.