Eliminating co-payments is better for patients who have had a heart attack; their outcomes are better, they are more likely to adhere to their treatment regime, and costs are lower, researchers from Brigham and Women's Hospital and Harvard Medical School revealed today in NEJM (New England Journal of Medicine as well as the American Heart Association Scientific Sessions. Although drugs can reduce the risk of subsequent cardiovascular events for heart attack patients, adherence rates are generally poor.

Adherence is the process in which a patient follows his/her doctor's instructions, including when to take certain medications.

In this study, the researchers set out to determine whether eliminating co-payments for post-heart attack medications might improve adherence and provide better outcomes.

Lead author, Niteesh Choudhry, MD, PhD, said:

"The elimination of co-payments for certain medications following a heart attack resulted in improved patient adherence to the medications and positively impacted rates of major vascular events.

While the elimination of cost sharing did not significantly alter the trial's primary end-point, which included revascularizations along with vascular events, the intervention was successful in reducing rates of important clinical outcomes, lowering the amount that patients spent on medications and other non-drug health services, and did not increase overall health care costs."

The investigators gathered data on 5,855 patients who had been enrolled by health insurance company Aetna Inc. They had all been hospitalized for a heart attack and then discharged.

The patients were randomly assigned into:
  • A full prescription medicine coverage insurance plan - 2,845 patients
  • A typical prescription medicine cover plan, which included cost-sharing - 3,010 patients
Both plans provided coverage for ACE inhibitors, beta blockers, statins, and angiotensin-receptor blockers - drugs routinely prescribed for patients after a heart attack.

The patients were carefully monitored so that the researchers could track their drug-adherence rates, as well as how many major vascular events they suffered. Examples of major vascular events included being readmitted to hospital for heart attack (fatal or non-fatal), stroke, heart failure, or unstable angina. They also tracked their incidence of angioplasty or stent procedures (revascularizations). How much out-of-pocket costs were for the patients as well as their overall health care spending were also determined.

They found that the elimination of co-payments:
  • Did not significantly improve combined endpoint of major cardiovascular events and revascularization
  • When calculating all events, and not just the first one, the rate went down by 11% in the full prescription medicine coverage insurance plan group (intervention group)
  • Rates for first vascular event was 14% lower in the intervention group when revascularizations were taken out of the equation.
  • Total healthcare spending for those in the intervention group was not significantly higher than in the other group.
  • Out-of-pocket expenses for those in the intervention group was 26% lower.
Choudhry said:

"This research shows that by eliminating co-pays for patients who are prescribed medications that are proven to be effective, patients will use them more. In this specific study, adherence to these medications increased four to six percentage points. Even with this improvement, overall adherence to these medications is very low, with less than half of patients who are prescribed these medications actually taking them.

While cost-related underuse represents 'low-hanging fruit' and the intervention we evaluated appears cost-effective, more work is needed to identify other effective strategies for increasing adherence as a way to improve patient care and simultaneously lower the cost of providing care to these patients."

Aetna Inc. and The Commonwealth Fund paid for the study.

Lonny Reisman, M.D., F.A.C.C., Aetna's chief medical officer, said:

"As a cardiologist, I know that optimal clinical outcomes depend on patients following recommended treatments. Today's cardiac medications are well established in greatly reducing a patient's chances of having a second heart attack - and living longer. Still, only about 40 percent of patients follow the medication regimen after having a heart attack.

Armed with new and growing evidence about patient behavior, we can help high-risk members address their personal barriers to adherence."

According to Aetna Inc., patients stop taking their medications because:
  • Access
  • Cultural barriers
  • Lack of understanding
  • Side effects
  • They cannot afford the payments - costs
Written by Christian Nordqvist