Like most people my age I am taking some medications regularly
and got the text message today from my pharmacy that I could pick up one of
those prescriptions. The medication is a commonly prescribed medication from a
group of medicine called Non-Vitamin K
antagonist oral anticoagulants or NOACs.
The medication is apixaban or Eliquis. People commonly take it to
prevent blood clots or emboli and the complication including stroke, thrombosis,
and pulmonary emboli. I have been taking it for about 2 years.
I usually get a prescription for 180 – 5 mg tabs and the
last time I picked it up was on May 25, 2023.
At that time there was a copay of $94. I am on Medicare A and B and a
Medicare Supplemental Policy.
This time as I drove through the line the pharmacist told
me the copay was $500. I asked him to clarify what had happened, but he had no
idea. Even though I had all of my
previous refills at this pharmacy he had no idea what had happened and advised
me to call the insurance company. When I got home that is exactly what I did.
They advised me that this was the standard coverage gap for prescription
drugs also known as the donut hole. The
insurance company pays for $4660 worth of medication (in my case almost all
apixaban) and at that point copays stop and the patient is responsible for a
flat 25% of the total cost of the medication or the $500). When the patient incurs a total of $7,400 in pharmaceutical
costs the number falls to 5% of the total, but by then it is probably a new
year and the running tally resets. The customer service rep told me that I
might be able to apply for assistance through company or state program, but
they all had low-income requirements.
The donut hole started in 2006 as a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. All Medicare Part D plans have it. It initially required patients to pay 100% of the drug cost during the coverage gap. That was reduced to the current 25% by the Affordable Care Act (ACA) passed in 2010. By 2025 there will be a cap of $2,000 for costs incurred in the coverage gap.
It turns out that apixaban is number 10 on the list of 17
most expensive drugs purchased through Medicare programs. In 2019, the average person taking it spent $7,234
for 12 refills per year and $2,172 in out-of-pocket costs. A reform of this pricing has been suggested
but obviously has not been done since I am paying about the 2019 list price. The
top drugs on this list are easily not affordable for many people. The cost of
the top 5 agents are $16,348 to $182,162 per year with out-of-pocket costs ranging
from $3,242 to $11,532 due to the coverage gap (1). Apixaban in the single largest Medicare Part D expenditure at $12.5 billion per year (last filed in 2021).
Flashbacks of my work in acute care. For 22 years, I
treated low to no income people in acute care settings. I was lucky to work
with excellent social workers who would exhaust every available resource to
help them with funding for medical care and housing. Getting their medications funded was a chronic
problem. People on Social Security
Disability do not get a lot of money each month. At one point the state instituted a spenddown. That meant if you were hypothetically making
$1,000/month in disability payments, the state could demand that you spend a
significant portion of your disability on medications before they would add any
additional money for that purpose. It is
not possible to live very well – if at all under those financial constraints.
One of our attempts to adapt was to use the company scholarship
programs to get them assistance from pharmaceutical companies. With many
patients that took a great deal of coordination and filling out forms. It also required nursing time for both the paperwork
and an additional effort to manage free samples of medication. We were often scrambling
to find medications in urgent situations or because one of the authorizations
had lapsed. All the samples also had to
be catalogued by lot number in case there was a recall of that medication. I
did not look forward to dealing with the forms or samples but realized we had
to do it or some people would not get the medication they needed.
Today the tables were turned and I was looking at an
arbitrary payment or I would not get the medication. I have also heard this story many times.
People unable to pick up a needed medication because of the copay – leading to
an abrupt discontinuation or attempting to stretch out an existing medication
until the first of the year. You really cannot stretch out an apixaban prescription. I have read many news stories about people
trying to stretch out their expensive forms of insulin resulting in medical compromise
and death. I was lucky enough to have savings to cover the $500.
What are the problems with the donut hole? I can think of at least 4:
1: It kicks the can down the road (also known as cost
shifting). When confronted with these large payments, I can imagine a lot of
people tell the pharmacist to forget about it and drive away. In the case of
this medication that can lead to strokes, pulmonary emboli, thrombosis of
large blood vessels, and/or death. Treatment typically
involves hospitalization and possible nursing home placement. Worst case scenario might involve death, prolonged
rehabilitation and the hospital or nursing home eventually seeks all of a
patient’s assets to cover the accumulating bills. All of those events could have been prevented
with the prescribed medication.
2: The structure of
this billing is an incentive for pharmaceutical companies to increase prices
since that will cause benefits to hit the wall earlier and cause the patient to
enter the coverage gap and to pay more cash. In fact, it is an obvious way to extract the maximum payment from both the insurance company and the patient.
3: It is another
classic example of how politicians work to subsidize businesses in a non-transparent
way. I know more about medical billing
than most people but I had no idea I was turning over $500 today until I was
advised by the pharmacist.
4: This is a clear
example of why the Republican and Libertarian ideas about "free
market" healthcare are false. In
other words, we would choose to pay for what we really wanted in a free market
and pay those market prices. Obviously,
anyone would pay $500 (or more) to prevent a stroke - but not if it means not
eating. The politicians involved will
say: “well yes – but there is no free market.”
Of course, there is no free market. The market is actively manipulated to
optimize profits for health care companies and minimize guidance from
physicians. That is the political system in the US. No doctor that I know of
wants to prescribe a medication and hear at some point that the patient could
not afford to take it. Sometime that news is very slow and the prescribing doctor
does not find out until they see the patient back in a couple of months.
Don't ever think that American "free market"
capitalism is a big deal in health care.
It is a big deal when politicians work with businesses to give them access
to your assets and allows other businesses with more focal products like
pharmaceuticals to charge whatever they want. There is no better example than the donut
hole. The cost savings that these companies promised is not from cost containment, but from rationing and that is a big difference.
George Dawson, MD, DFAPA
References:
Dusetzina SB. Relief in Sight - Estimated Savings under
Medicare Part D Redesign. N Engl J Med. 2021 Dec 23;385(26):e93. doi:
10.1056/NEJMp2116586. Epub 2021 Nov 10. PMID: 34758246.
Supplementary 1:
I downloaded this list of medication arranged by total Medicare Part D expenditure from the CMS web site on 8/26/2023. The most recent data they have is for 2021. Medications for psychiatric indications do not appear until # 24 Invega Sustenna and #31 Latuda. More than a little interesting because psychiatrists have endured medication based attacks for over 20 years - primarily on grossly inflated conflict of interest concerns, pharmaceutical company profits concerns, and drug safety. Many of those attacks continue today even though most of these medications are inexpensive generics and much of the rhetoric has lost its punch. These same critics apparently have no similar concerns about significantly more profitable and higher risk medications. That adds to my commentary in this post.
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Medicare Drugs Selected by HHS for Price Negotiations |
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Eliquis |
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Jardiance |
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Xarelto |
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Januvia |
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Farxiga |
|
Entresto |
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Enbrel |
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Imbruvica |
|
Stelara |
|
Fiasp; Fiasp
FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill |
|
|
|
|
Graphic Credit:
Evan-Amos, Glazed Donut Public domain, via Wikimedia
Commons"
Link:
https://commons.wikimedia.org/wiki/File:Glazed-Donut.jpgalt="Glazed-Donut
File:
https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Glazed-Donut.jpg/512px-Glazed-Donut.jpg
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