http://www.pcmanet.org/images/stories/uploads/2011/Nov2011/visante%20copay%20coupon%20study.pdfFirst, let’s look at the basics. Given the audience here, I’m sure you’ve all read the Visante study that they did for PCMA in November of 2011.
The availability of these programs is growing. You can go online and find these programs at many sites, and you can see the growth here. The unknown question is how much they are being used. Today, everyone I talked to is struggling with how to tag which claims process with a copay card used.
But, the lack of data is something that makes this an opaque topic. If the data ever becomes transparent, this issue will either quickly die or will get magnified based on what that shows. Until then, the official PBM position is that copay cards are bad. I talked to almost all of the top 10 PBMs over the past few weeks to validate this.
And, last summer, I had 16 different PBMs participate in a survey on the topic. As you can see here, they were generally concerned, but they weren’t sure of the impact.
On the other hand, even though there are more and more copay cards out there, the actual utilization of 3rd tier drugs has actually dropped over the years although the range is pretty narrow.
That being said, I think Everett’s quote from Express Scripts does a pretty good job of summarizing this if you really get behind the immediate reaction.
So, the reality is more complex. It takes into account the drug type (traditional versus specialty). It begins to look at the purpose of the copay card. Of course, no one has issues with PAP programs. The issues really are around commercial business where copay cards may influence patient decisions about drug selection and minimize the traditional PBM tools of formulary and copay.
Here’s generally how I look at the situation moving from the type of drug on the X axis and looking at the timing in the Y axis.
http://www.healthbusinessblog.com/2011/08/drug-co-pay-cards-can-we-all-just-get-along/Or here’s another similar quote that came out after my AIS webinar last year where I suggested that maybe there was a win-win around copay cards.
I personally struggle with some of the fundamental assumptions about why copay cards are used. The data is not clear in supporting what I believe are the primary assumptions for funding these programs.
Let’s look at one of the biggest myths out there first. Cost. While the latest data shows that 50% of the US population now is on the government payroll through food stamps, Medicare, Medicaid, Social Security, or other assistance, the Kaiser data here only shows 20% of people not filling a prescription as part of their card avoidance.
This is consistent with our data at Silverlink that shows only 14% of people not taking some healthcare action based on cost. Our 243,000 barrier surveys were done over the past 2 years looking at preventative activities and refill data.
So…if cost isn’t the issue, then one might assume that copay cards are great influencers of physicians that understand the cost of the medications that they prescribe and want to help their patients. But, again, if you look at the published data by Will Shrank, it shows that physicians don’t worry about formulary or OOP costs. They see that as the pharmacist’s job.
The next key assumption is that these copay cards work. I talked to several people that manage these programs and the data wasn’t clear. In the best case, it appeared that they increased the average days supply for a patient by 30-45 days (or about 10% improvement in PDC or MPR). And, according to the Visante study with PCMA, these programs get a 4:1 – 6:1 ROI leading to about $4B in spend a year.
http://www.drugchannels.net/2012/01/is-pfizers-lipitor-strategy-working.htmlThe last key question or myth here is that copay cards will slow the shift to the generic after the patent expires on a brand drug. We have a great case study unfolding before our eyes. One the one hand, I have to hand it to Pfizer for creatively trying a number of programs to sustain the brand utilization. And, most of the data seems good. But, Adam Fein shared a chart a few weeks ago that created some skepticism here. He shows that the shift to generics for Lipitor is actually happening faster than in prior cases…even with all the efforts by Pfizer. (I was surprised.)
Of course, if I’m sitting in your seats and I’m responsible for a drug, I’m focused on the issue of copayments going up. As this study from JAMA showed and we’ve all talked about relative to VBID, copay increases do affect adherence…
http://www.benefitdesignreport.com/CostSharing/RetailCopays/tabid/84/Default.aspxAnd, copays continue to go up. Although as a percentage of drug costs, they’ve stayed flat for years.
But, the question now is how will PBMs and payers respond to increased use of copay cards. On the one hand, you have CVS Caremark who removed over 30 drugs from their 2012 formulary with about ½ of them having some type of copay card in the market. Generally, when I talked to PBMs, this was their primary reaction. It’s the cleanest and most effective strategy, but it’s also the most disruptive. This slide shows the spectrum of opportunities. Of course, as David Snow talked about last year, they’d all like to figure out how to do this at the POS, but that hasn’t happened and seems to be more difficult as copay cards look more like pre-paid debit cards.
And, when I survey people last year, you can see that this was where people felt strongest.
Increasing mail order utilization was another easy answer to avoid use of copay cards since most PBMs won’t accept them. This is an interesting one since PBMs generally don’t want brands at mail order since they don’t make money there (generally). And, given the mail order drops over the past few years, this is a challenge for them in general and copay cards have created some buzz about pharma wanting to actually encourage 90-day retail utilization for this exact reason.
At the end of the day, it’s still a confusing topic. The constituents are torn. The data is inconclusive. There are issues that exist.
But, I personally believe that copay cards that were used tactically to address adherence, improve outcomes, and reduce overall healthcare costs could be a win-win. That’s a hard sell on MSBs like Lipitor, but a lot easier on specialty drugs. On the flipside, as a I mentioned earlier, I think pharma could collaborate with payers to drive adherence in less controversial ways.
So, what I proposed last summer was the following which I still think makes sense:
Wizard of Oz pulling back curtain THE PERCEPTION. There is an “untrackable” mechanism which pharma has created to get around formularies and directly influence patient and physician drug selection4 | FEBRUARY 2012
Wizard of Oz pulling back curtain THE PERCEPTION. There is an “untrackable” mechanism which pharma has created to get around formularies and directly influence patient and physician drug selection THE REALITY. Co-pay cards are a multi-dimensional issue with limited facts and some opportunities for win-win.8 | FEBRUARY 2012