By Andrew Pollack
The New York Times
January 1, 2011
With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments.
Drug companies say the plans help some patients afford medicines that they otherwise could not.
But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.
Any shift to brand-name drugs can have a big impact on health care costs.
At District Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.
For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug. Novartis’s new pill for multiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.
Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies & Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.
Drug companies cannot offer co-payment assistance for patients in federal programs like Medicare because such offers are considered an inducement to use a drug and in violation of anti-kickback laws. Some companies have responded by contributing to, or even helping to set up, charitable foundations that can provide co-payment assistance legally.
Executives at insurers and pharmacy benefit management companies say they would like to counter the cards and coupons but are not sure exactly how to do so. One problem is that the information they receive from pharmacies does not specify whether the co-pay was made by the patient or by the drug company.
“The payer doesn’t know, and the P.B.M. doesn’t know,” said F. Everett Neville, chief trade relations officer at Express Scripts, a pharmacy benefits manager. “We have no ability to stop it and no ability to prohibit it.”
By Don McCanne, MD
Should a health care system be designed to ensure that patients receive appropriate medications that they should have to relieve symptoms or cure disease? Of course. Yet co-payments (a dollar amount) and coinsurance (a percentage of the cost) impose on the patient financial barriers to the medications – barriers which frequently are not surmounted, and thereby may result in impaired health outcomes.
With our fragmented system of financing health care those seeking greater profits will always find another way to achieve their goals. In this instance, the pharmaceutical manufacturers have found a way to reduce or eliminate these financial barriers to their products.
In providing cost-sharing assistance to the patient, the manufacturers are not specifically removing barriers to the most appropriate products, but rather are removing barriers to their most profitable products, irrespective of whether or not they are the best choice. Since these are more expensive products, that increases the drug costs of the private insurers. Those of us paying premiums to private insurers that cover drugs are paying for these excess costs.
These practices do not require collusion with the physicians and pharmacists since their marketing practices are effective in creating a demand for their products regardless of the appropriateness.
Note that these pharmaceutical industry subsidies of co-payments and coinsurance are illegal in federal programs such as Medicare because they are the equivalent of kickbacks. If we had a Medicare program that covered everyone and eliminated the private intermediaries such as the insurers and pharmacy benefit managers, then these kickbacks wouldn’t exist. Drugs would be prescribed based strictly on appropriateness, and would be priced to provide fair profits for the pharmaceutical firms and fair costs for Medicare.