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CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

November 15th, 2011

MI FREE: A Free Lunch for Patients and Insurers Alike?

Several Cardiology Fellows who are attending AHA.11 this week are blogging together on CardioExchange.  The Fellows include Revathi Balakrishnan, Eiman Jahangir, John Ryan (moderator), and Amit Shah. Read the previous post here. Check back often to learn about the biggest buzz in Orlando.

In MI-FREEE presented by Dr. Niteesh Choudhry today at AHA and published online in the New England Journal of Medicine, 5855 AETNA-insured patients were randomized at discharge for MI patients to either normal coverage or no copay for statins, beta blockers, ACE inhibitors and ARBs. Patients in the no-copay group were significantly less likely to have another major cardiac event (MI, angina, heart failure, or stroke) compared with the normal coverage group: 11 per 100 person-years vs 12.8 per 100 person-years, respectively; P=0.03). Not surprisingly, removing copay increased medication adherence.

What did surprise me was that this protocol so substantially decreased costs for  Aetna — which sponsored the trial — that they are now introducing the Aetna Rx Healthy Outcomes program, which will decrease copays for MI patients.

There is often skepticism surrounding the results of pharmaceutical-sponsored trials in light of the financial benefits to the company. Here removing copays saved Aetna over $5000 per patient, with a total pool of 40 million people covered by Aetna insurance plans. Should the same concerns that apply to pharmaceutical-sponsored research apply to the insurance industry? Why or why not?

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4 Responses to “MI FREE: A Free Lunch for Patients and Insurers Alike?”

  1. Siqin Ye, MD says:
    November 15, 2011 at 1:40 pm

    With pharmaceutical sponsored research, the concern is that direct commercial interests will create bias and influence results, i.e., there will be “spin” to promote a new drug or device when the actual benefit may be small or null. With the MI-FREEE trial, it’s hard to imagine that removing co-pay is a way to promote any new prodocts; rather, this is answering more of policy / healthcare delivery question.

    When I debate these issues with my co-fellows, a lot of them will say that any sponsored research (e.g., NIH) still create incentives that bias towards positive results just by the nature of how academic works. While this is true, I do believe that these kind of biases operate on a different level than commercial ones (which is not to say that pharmaceutical sponsored research are not valuable or are inherently flawed).

  2. Amit Shah, MD says:
    November 15, 2011 at 3:11 pm

    I agree — this might as well have been an internal quality improvement study for Aetna. I don’t see any reason to fudge or bias any results, other than perhaps gaining some public relations benefit. Are clients more likely to chose Aetna now because of this? Not really clear, but it definitely elicits positive feelings towards them.

    I like this trial also because it is hopefully the beginning to more good things in terms of the way we see health care. The trends are now going towards higher copays for visits and drugs. While for healthy patients that may reduce short-term costs, I think in the long run it backfires. Anyone know of similar studies in other groups perhaps? I would imagine that patients with CHF would experience similar benefits. Perhaps a larger debate is the cost-effectiveness of removing copays for other higher risk groups such as diabetics.

    Another alarming point about this study is the measly adherence rate, which were generally around 50% for each drug, even when copays were eliminated. It begs further questions…why? Are my patients lying to me when they tell me they are taking everything? Am I too naive? Clearly more work needs to be done in this area…

  3. John Ryan, MD says:
    November 15, 2011 at 3:36 pm

    Thanks for the comments- I suspect that a policy such as this will increase the footprint of Aetna, but if patients get better and cheaper care, then I think this could welcome a new era of trial-sponsorship.
    And Amit is right too- it seems at a compliance of 50%, we literally cannot give the meds away. Does giving the patients the medicines directly improve compliance (rather than relying on them to go to the pharmacy or mail in the script)?

  4. Reva Balakrishnan, MD, MPH says:
    November 15, 2011 at 4:05 pm

    This was a fascinating study that answered a question that I think we’ve always wondered about when we see difficult patients in clinic. I think an interesting follow-up to this study would be to look at improvement in adherence using this strategy in specific populations that are at an even higher risk for poor outcomes, such as those with high readmission rates; perhaps from a hospital quality improvement standpoint. I wonder how much of a role medication cost really plays in adherence when one has a high disease burden and potentially complex social support situations. The medication possession ratio was the tool used to assess adherence, which measured how people filled their prescriptions, and full adherence was defined as “medication possession >80%”; short of having an electronically monitored pillbox to monitor adherence (which is currently being studied), I don’t think we will every really know for sure when patients are telling the truth about taking their medications!