2018 Reviews on Healthcare Alliance Pharmacy Discount Card
CMAJ. 2019 Nov 11; 191(45): E1237–E1241.
Bear on of brand drug discount cards on private insurer, government and patient expenditures
Abstruse
BACKGROUND:
Brand disbelieve cards accept become a popular fashion for patients to reduce out-of-pocket spending on drugs; however, controversy exists over their potential to increase insurers' costs. Nosotros estimated the touch on of brand discount cards on Canadian drug expenditures.
METHODS:
Using national claims-level pharmacy arbitrament information, we performed a retrospective comparison of prescriptions filled using a brand disbelieve menu matched to equivalent generic prescriptions between September 2014 and September 2017. We investigated the bear on on expenditures for 3 groups of prescriptions: those paid only through individual insurance, those paid simply through public insurance and those paid only out of pocket.
RESULTS:
We studied two.82 million prescriptions for 89 different medications for which brand discount cards were used. Utilize of discount cards resulted in 46% higher private insurance expenditures than comparable generic prescriptions (+$23.09 per prescription, 95% confidence interval [CI] $22.97 to $23.21). Public insurance expenditures were only slightly higher with cards: an increase of one.three% or $0.37 per prescription (95% CI $0.33 to $0.41). Finally, out-of-pocket transactions using a card resulted in mean patient savings of vii% or $3.49 per prescription (95% CI −$3.55 to −$iii.43). The bear upon varied widely amongst medicines beyond all 3 analyses.
INTERPRETATION:
The utilise of make discount cards increased costs to individual insurers, had little touch on public insurers and resulted in mixed impacts for patients. These effects likely resulted from individual insurers reimbursing make drug prices even when generics were available and from discount cards being adjudicated after claims were sent to other insurers in most cases. Patients and their clinicians should recognize that discount cards have mixed impacts on out-of-pocket costs.
Over the past decade, many pop drugs have lost their patent protection and have get available equally generics.i As the prices of brand name medications are typically greater than the prices of equivalent generics, many individuals switch to a generic once bachelor, and insurers often impose rules to maximize the use of generic drugs. In an effort to maintain market share without reducing listing prices, many brand manufacturers have introduced patient discount cards.two , 3 In Canada, patients can obtain these cards through multiple sources, which include signing upwards on websites or obtaining them from pharmacies and from physicians' offices. The cards are adjudicated at the chemist's in a style similar to an insurance plan to reduce the cost of the prescription for a branded product.4 Since their introduction, these discount products have been widely used: a coupon was used for an estimated 20% of brand prescriptions in US commercial insurance plans in 2016,5 and more than than 1.five meg individuals accept signed upwardly for a single provider's cards in Canada.6
These discount cards have been controversial considering of their potential touch on on drug expenditures. Although the cards are more often than not thought to embrace plenty to make the patient's copayment similar to that of an equivalent generic, costs to insurers for the remaining portion of the drug can be higher.2 , half-dozen This increase in price for the insurer occurs considering the difference in cost betwixt the branded production and the generic is covered merely for the patient and not for the insurance plan. In item, this increased price is more likely when the claim is sent to the insurance program for adjudication before the menu is applied, making it seem to the insurer that the patient is filling a standard brand prescription. For this reason, in the United States these cards are prohibited in public insurance plans (including Medicare and Medicaid), and 3 states have either laws or pending legislation limiting their use.7 Legislation has also been passed in the province of Quebec to limit their apply, but the accompanying regulations have not been developed, and this aspect of the law is therefore not in strength.eight The cards remain legal, therefore, in individual plans in the US and for both public and private insurance plans in Canada.
Despite the controversy surrounding their use, we are not aware of whatever studies that have directly quantified the bear upon of these cards on the amounts paid by individual insurers, public drug plans and patients. There have been a few U.s. studies comparing branded products with these discount programs and their generic contest, which found mixed impacts on adherence and toll.9 – eleven However, these studies were mostly descriptive and unadjusted, and the economic affect of discount cards remains unclear. Therefore, we used comprehensive pharmacy adjudication records to study the utilize of discount cards and their impact on costs for different payers in Canada.
Methods
Study setting
Although Canada operates a universal national insurance program for doctor and hospital services, prescription drugs are funded through a mix of public coverage, private benefits coverage (which is largely employer-based) and out-of-pocket patient charges. Before the introduction of discount cards, it was not typical for branded manufacturers to lower prices when generic alternatives became available. Brand discount cards can be used in conjunction with any type of programme and are adjudicated at the chemist's shop in the same manner every bit any other public or private insurance program. We focused on cards that offered discounts on branded products for which a generic equivalent was available (as opposed to new drugs without approved generics).4
Data sources
For our report, we used chemist's shop adjudication records from across Canada that were provided to Bounding main to Sky Health Ltd., a wellness data enquiry and consulting company owned by i of usa (M.50.), by a large, national data source. This data set consisted of a convenience sample of chemist's shop adjudication records from the automated systems used to procedure claims at more than 1000 community pharmacies across Canada, including every province and age group. These data included data on patients who used i or more than disbelieve cards between September 2014 and September 2017. The data gear up included both the transactions using a make discount card and all transactions from the aforementioned individuals involving equivalent generic drugs from the automated systems that procedure claims.
Nosotros assessed the validity of our data using several checks, including assessing the range in values for the individual variables, identifying trends over time in the use of medicines with cards and comparing prices with those on the Ontario public formulary for a random subset of 100 specific medications with more than than thousand claims (selected by Drug Identification Number). All of these values were within 5% of what would accept been expected on the basis of allowable ingredient costs and markups. Considering the data set was derived from actual pharmacy arbitrament records, at that place were no missing data. Our research team was provided with the original raw information, performed all information cleaning, designed the analytic approach and derived all of the results presented below.
For each transaction, we obtained data on each payer that contributed to payment (including dispensing fees and markups), specifically private benefits plans, public (authorities) insurance programs and cash payments from individuals. Our data set up outlined the club in which payments from dissimilar sources were adjudicated, and how much each paid toward the total cost of each prescription. This ordering is important because if insurance plans cover a percentage of the full cost and are adjudicated earlier a discount card, and so they will pay a higher portion of the total cost.
From the data set of transactions using a make discount card, we derived 3 distinct cohorts of prescriptions: a private benefits accomplice, a public benefits accomplice and a cash cohort. First, to isolate the bear upon of discount card use on individual insurance plans, we selected transactions for which a private benefit plan paid a portion, with no public drug plan paying any portion (the private benefits cohort). Then, nosotros selected transactions for which a public drug program paid a portion of the transaction, with no individual do good plan paying whatever portion (the public benefits cohort). Finally, we selected transactions in which only greenbacks payment from the patient was involved (i.e., no individual or public drug coverage, the cash cohort). In cases in the private benefits plan cohort in which multiple plans were used (e.thousand., a spousal plan in addition to the person's ain plan), we summed all plans.
Statistical analysis
For each of the 3 cohorts of prescriptions, we matched the claims to equivalent generic prescriptions on the ground of exact matches for the post-obit characteristics: agile ingredient, based on Health Canada Active Ingredient Groups; dosage strength; form (eastward.g., tablet, extended-release capsule); quantity; and province of dispensation.
With these equivalent prescriptions, we compared the difference in cost for the brand prescription using a discount card and for equivalent generic prescriptions for private benefits plans, public drug plans and patients. Nosotros calculated 95% confidence intervals (CIs) for these differences and tested statistical significance using t tests.
Ethics approval
This written report was approved by the University of British Columbia Behavioural Inquiry Ideals Board.
Results
Over the period of our study, make disbelieve cards were used ii.82 million times for 89 different medications. Over the 3 years we studied, monthly utilise of brand discount cards grew by 67% (Appendix one, Figure 1A, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190098/-/DC1). Cards were used slightly more frequently past women (54%), and the average age of patients was 50 years. Use of discount cards was heavily concentrated within a few medicines: the pinnacle 5 in terms of utilization numbers (rosuvastatin, buprenorphine/ naloxone, methylphenidate, escitalopram and atorvastatin) accounted for 53% of all cards used. By drug, discount cards paid a median of 44% of the toll of each prescription when they were used, but there was substantial variation in this number (interquartile range 29% to 55%). This percentage did not substantially increase or decrease over our study period (data not shown). In terms of payer order, in well-nigh cases (88%) payment claims for the drug was submitted to private benefits plans earlier the discount menu.
Private benefits cohort
Our cohort contained 939 608 claims that involved a private insurer and no government payment (summit xv shown in Appendix ane, Table A1), which we compared with 995 149 equivalent generic claims. Overall, third-party insurers paid $69.four 1000000 toward these claims compared with an estimated $47.seven million for the same mix of equivalent generic prescriptions. This equates to an increase of $21.7 million, or 46%. On a per-prescription basis, this represented a cost increase of $23.09 (95% CI $22.97 to $23.21) for individual insurers. This increase in expenditure extended to all of the individual drugs that we studied: in every case, employ of a brand card led to college expenditure for private drug plans in comparison with equivalent generics. Effigy i shows the estimated change in expenditure for the meridian 15 most popular discount cards, where the per-prescription increase by drug for private insurers ranged from $2.90 to $46.91.
Average change in reimbursement per prescription for individual insurers and individuals for the top 15 medicines using brand disbelieve cards when compared with equivalent generic prescriptions without a disbelieve card (express to prescriptions with merely individual insurance and out-of-pocket payment). Positive values stand for increases in reimbursement when a brand disbelieve card was used relative to an equivalent generic.
In dissimilarity, there was trivial overall modify in the out-of-pocket component for these prescriptions. Patients paid $7.1 million toward the prescriptions with a brand carte, compared with the estimated $seven.2 million they would have paid for the same mix of generic versions, for a departure of $108 000. This represents a two% saving per prescription for patients, or a $0.12 saving (95% CI −$0.15 to −$0.08). As shown in Figure 1, the change in out-of-pocket expenditures by patients for the top 15 drugs was much smaller than for insurers, ranging from an average saving of $4.15 to an additional cost of $6.19.
Public benefits accomplice
We found a similar number of claims, 901 200, with payment from a public drug program and no private insurer payment (top 15 shown in Appendix 1, Table A2). These claims were compared with 1.45 one thousand thousand equivalent generic drug claims with the aforementioned payment characteristics. Overall, government plans paid $26.0 one thousand thousand toward these claims when a discount card was used, and we estimate they would have paid $25.7 million for equivalent generics, for a difference of $334 000. This represents an increase of 1.iii%, or $0.37 per prescription (95% CI $0.33 to $0.41). Equally shown in Figure 2, the change in public drug plan expenditure was insufficiently small, ranging from a saving of $1.43 per prescription to an increase of $ii.49 per prescription.
Average change in reimbursement per prescription for public drug plans and individuals for the superlative 15 medicines using make disbelieve cards when compared with equivalent generic prescriptions without a discount carte (limited to prescriptions with only public drug program and out-of-pocket payment). Positive values represent increases in reimbursement when a brand discount card was used relative to an equivalent generic.
Overall, patients paid $iv.1 meg for brand prescriptions in this cohort, whereas equivalent generics would have toll $2.4 million. This represents an estimated increment in out-of-pocket payment of $1.seven million, or $ane.86 per prescription (95% CI $1.84 to $1.88). As shown in Effigy 2, there was substantial variability in this impact for patients, with many drugs in the superlative fifteen showing virtually no effect on out-of-pocket payments, whereas 4 had much higher per-prescription amounts: from $4.78 higher for clopidogrel to $11.71 higher for atorvastatin.
Greenbacks cohort
Our final analysis focused on transactions involving merely out-of-pocket payment from the patient (i.e., no private or public drug coverage). In that location were 376 838 such transactions that used a brand discount carte du jour, which we compared with 355 426 claims for equivalent generics (acme 15 shown in Appendix 1, Tabular array A3). Overall, patients paid $17.3 million for the branded prescriptions with a discount card, and we estimated that they would have paid $18.seven million for equivalent generics. This represents a saving of $i.3 one thousand thousand or seven% on out-of-pocket payments, or an average of $3.49 per prescription (95% CI −$3.55 to −$iii.43). As shown in Effigy 3, there was variability in these values for the peak 15 drugs, ranging from a saving of $xiii.44 per prescription to an increased cost of $8.44 per prescription.
Boilerplate change in out-of-pocket payments per prescription for individuals using make discount cards when compared with equivalent generic prescriptions for the top 15 most frequently used cards (limited to prescription claims with merely out-of-pocket payments). Positive values represent increases in patient payments when a brand disbelieve carte was used relative to an equivalent generic. For desogestrel/estradiol, "28" indicates Marvelon 28, and "21" indicates Marvelon 21.
Interpretation
Nosotros found that the use of drug discount cards issued by the manufacturers of brand name drugs has increased in Canada and that the cards are used for a broad range of dissimilar drugs. Overall, we found that the impact of these cards on drug expenditures depends on the payer in question: the cards universally and substantially increased expenditures by private insurance companies just had very petty impact on public drug plan expenditures. In terms of out-of-pocket payments, the touch on differed according to both insurance status and the specific drug in question: in some cases patients saved money using a disbelieve menu, whereas in other cases they spent more.
The difference in impact between individual insurers and public drug plans probable arises from the different payment rules in these plans. Although near every public drug plan in Canada will pay but the generic price when a generic is available (even when a make version is dispensed),12 this is not the case for many private drug plans. In fact, simply about half of individual drug plans in Canada have rules whereby they will pay simply the amount of the equivalent generic when 1 is bachelor.xiii Our report provides empiric show that drug disbelieve cards represent a way for pharmaceutical companies to leverage this discrepancy while making patients' copayments nearly equivalent, and so as not to deter them from filling their prescriptions with branded medicines. This occurs despite the fact that, in nigh cases, it is not necessary to use the brand name version of a drug molecule when a generic culling is available, as evidenced by many studies showing clinical equivalence between branded products and their generic counterparts.14 – 16 Finally, nosotros observed much heterogeneity in the affect on cash payments past patients, which likely resulted from different adjudication rules for different medications.
Limitations
Although our study benefited from use of a very large, national data source and strong comparisons through the use of equivalent prescriptions, there were also some limitations. Considering the data did not plant a comprehensive record of all prescriptions received by the individuals included in the study, we were unable to appraise the extent to which the make discount cards affected important outcomes such as medication adherence. Our information prepare was a convenience sample and did not comprise information on claims at every Canadian chemist's shop. However, we have no reason to believe that the adjudication rules of the discount cards, public insurers and private insurers would vary elsewhere. Our written report was completed during a menstruum when generic drug prices were decreasing in Canada. However, if this timing resulted in any bias, it would be conservative in direction and would consequence in our underestimating the true outcome on private insurers. Furthermore, although our results are clearly relevant to Canada, it may not be appropriate to extrapolate them completely to other countries with different reimbursement regimes. However, we believe that the bear on of cards on private insurers may be even higher in the US, given that country's lower generic drug prices and the fact that these programs exist for a larger number of drugs in the United states of america.17 It remains unknown how different insurance rules — most notably the more common use of tiered copayments in private drug plans in the Usa versus the more common use of coinsurance in Canada — would alter the impact.18 , 19 Finally, we were unable to assess whether the use of make disbelieve cards affected private insurance programme premiums.
Conclusion
The utilize of make discount cards is increasing in Canada, and their bear on depends on the payer in question. Given that our analysis showed large increases for private plans, employers might consider adopting more than stringent generic substitution policies to ensure value for money in drug spending. While governments demand non make such changes, they should be aware of the potential for increased out-of-pocket payments with some drugs and for expenditures in the private drug plans for government employees. Finally, regardless of whether they concord insurance, individuals should check relative prices at their chemist's between the brand with a discount card and the equivalent generic, given the possibility that they may be worse off financially if they employ a card. Clinicians should inform their patients that differences in cost exist betwixt make name and equivalent generic drugs, particularly if they are involved in distributing these cards. Time to come studies should rigorously evaluate the clinical impact of brand discount cards, such every bit effects on adherence rates relative to non–card users.
Footnotes
Competing interests: Michael Law has consulted for Health Canada, the Hospital Employees' Union and the Briefing Board of Canada, and he has provided testimony as an expert witness for the Attorney General of Canada. Mark Harrison holds the UBC Professorship in Sustainable Health Intendance, which is funded by Amgen Canada, AstraZeneca Canada, Eli Lilly Canada, GlaxoSmithKline, Merck Canada, Novartis Pharmaceuticals Canada, Pfizer Canada, Boehringer Ingelheim (Canada), Hoffman-La Roche, LifeScan Canada and Lundbeck Canada. No other competing interests were declared.
This article has been peer reviewed.
Contributors: Michael Law conceived of the report; caused, analyzed and interpreted the data; and drafted the manuscript. Heather Worthington, Mark Harrison and Fiona Chan contributed to designing the work and interpreting the information, and revised the manuscript for important intellectual content. All of the authors approved the final version to be published and agreed to be accountable for the work.
Funding: Michael Law received salary support through a Canada Research Chair and a Michael Smith Foundation for Health Research Scholar Laurels. Mark Harrison received bacon support through a Young Investigator Salary Laurels from The Arthritis Society (YIS-sixteen-104) and a Michael Smith Foundation for Health Inquiry Scholar Award 2017 (no. 16813).
Editor'southward note apropos data sharing: The provider of the database used for this study specified that the health research and data consulting visitor (Ocean to Sky Health Ltd.) enter into a confidentiality agreement in gild to have access to the data. As a result, CMAJ does not know the identity of the data provider and therefore cannot act as a guarantor for the data used, and the data are not available to others.
Disclaimer: The data provider and the pan-Canadian Pharmaceutical Alliance (pCPA) had no role in funding the report, developing the research methodology, conducting the assay or interpreting the results, nor in the decision to seek publication. In improver, the pCPA had no part in the provision of the data for this study. The pCPA was consulted during this report and, as a policy-maker, was interested in the subject affair.
References
ane. Cutler DM. The demise of the blockbuster? Due north Engl J Med 2007;356:1292–3. [PubMed] [Google Scholar]
two. Ross JS, Kesselheim Every bit. Prescription-drug coupons — no such thing every bit a gratis tiffin. Northward Engl J Med 2013;369:1188–9. [PubMed] [Google Scholar]
three. Grande D. The cost of drug coupons. JAMA 2012;307:2375–6. [PubMed] [Google Scholar]
four. PréMont MC, Gagnon MA. Trois types de stratégies des fabricants cascade la fidélisation aux médicaments de marque. Healthc Policy 2014;10:79–89. [PMC gratis article] [PubMed] [Google Scholar]
6. Take care [website for free drug payment card from InnoviCares]. Halifax: InnoviCares; 2018. Available: https://world wide web.innovicares.ca/en (accessed 2018 Oct. 25). [Google Scholar]
9. Felder TM, Palmer NR, Lal LS, et al. What is the evidence for pharmaceutical patient assistance programs? A systematic review. J Health Care Poor Underserved 2011;22:24–49. [PMC free commodity] [PubMed] [Google Scholar]
x. Daugherty JB, Maciejewski ML, Farley JF. The impact of manufacturer coupon use in the statin marketplace. J Manag Care Pharm 2013;xix:765–72. [PubMed] [Google Scholar]
11. Daubresse M, Andersen Thousand, Riggs KR, et al. Effect of prescription drug coupons on statin utilization and expenditures: a retrospective cohort study. Pharmacotherapy 2017;37:12–24. [PMC complimentary article] [PubMed] [Google Scholar]
12. Campbell DJT, Manns BJ, Soril LJJ, et al. Comparison of Canadian public medication insurance plans and the affect on out-of-pocket costs. CMAJ Open up 2017;five:E808–13. [PMC complimentary article] [PubMed] [Google Scholar]
13. Drug data trends and national benchmarks study. Montréal: Telus Health; 2018. [Google Scholar]
14. Kesselheim Every bit, Misono AS, Lee JL, et al. Clinical equivalence of generic and brand-proper name drugs used in cardiovascular illness: a systematic review and meta-analysis. JAMA 2008;300:2514–26. [PMC gratuitous article] [PubMed] [Google Scholar]
15. Hansen RA, Qian J, Berg R, et al. Comparison of generic-to-brand switchback rates between generic and authorized generic drugs. Pharmacotherapy 2017;37:429–37. [PMC costless commodity] [PubMed] [Google Scholar]
16. Hansen RA, Qian J, Berg R, et al. Comparison of outcomes following a switch from a brand to an authorized versus independent generic drug. Clin Pharmacol Ther 2018;103:310–7. [PMC gratuitous commodity] [PubMed] [Google Scholar]
17. Van Nuys K, Joyce G, Ribero R. Prescription drug coupons: a one-size-fits-all policy approach doesn't fit the prove [weblog]. Health Aff (Millwood) 2018. February16 Bachelor: https://www.healthaffairs.org/do/10.1377/hblog20180215.988517/total/ (accessed 2018 Oct. 25).
xix. Kratzer J, McGrail Yard, Strumpf E, et al. Cost-control mechanisms in Canadian private drug plans. Healthc Policy 2013;nine:35–43. [PMC free article] [PubMed] [Google Scholar]
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861153/
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