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HEALTH CARE POLICY Patients May Stop Meds in Move to Tiered Formularies Large increases in copayments in tiered prescription drug plans increase the likelihood that patients will stop buying prescribed drugs, including medications for heart disease and acid reflux, according to a study in the Dec. 4 New England Journal of Medicine. Employees may stop taking medications when their drug plans are dramatically changed, according to a study by Haiden Huskamp. (Photo by Graham Ramsay) "Tiered prescription drug plans are fairly new, but they now dominate the market with roughly 57 percent of workers in a three-tiered prescription drug plan," said lead author Haiden Huskamp, HMS assistant professor of health economics in the Department of Health Care Policy. "This is one of the first studies to show how employees being treated for chronic illnesses react to changes in their drug plans." When Copayments Rise The study followed two employers as they changed their prescription coverage plans in 2000 to incentive formulary plans. Employer A switched from a one-tier to a three-tier plan and increased copayments across all tiers. Employer B's employees went from a two-tier to a three-tier formulary with increased copayments for the third tier only. The study authors also identified two comparison groups, employers that had similar plans to Employer A and B, which allowed the authors to see what would have happened if no changes had occurred. Employer A's workers had a marked reaction after the substantial copayment increases. Some enrollees stopped taking necessary medications; for example, 16 percent of patients using tier-three ACE inhibitors to control blood pressure stopped taking their medications while only six percent stopped in the comparison group. Twenty-one percent of patients using tier-three cholesterol-lowering statins stopped taking their medications, though just 11 percent stopped in the comparison group. And 32 percent of patients using tier-three acid-relieving proton pump inhibitors stopped taking their medications while 19 percent stopped in the comparison group. Many of Employer A's other enrollees switched to a drug in a lower tier. Nearly 42 percent of patients taking ACE inhibitors switched their current tier-three medication to a lower-tiered drug, compared to four percent in the control group; 35 percent of patients taking tier-three proton pump inhibitors switched to a lower-tiered drug while only one percent switched in the comparison group; and 49 percent of patients taking tier-three statins switched to a lower-tiered drug versus 17 percent in the comparison group. Out of Pocket Due to the increase in copayments, the enrollees in Employer A's plan experienced a steep rise in out-of-pocket expenses. Relative to patients in the comparison group, patients in Employer A's plan paid 142 percent more for ACE inhibitors, 148 percent more for proton pump inhibitors, and 118 percent more for statins. Conversely, Employer B did not see a significant impact in compliance or spending among its members based on its modest plan change. Employer B's members, however, were more likely to switch from a nonpreferred brand name medication to a less expensive brand name or generic medication. Nearly 41 percent of patients taking ACE inhibitors switched to a lower-tiered drug (15 percent switched in the comparison group); 18 percent of patients using a proton pump inhibitor switched to a lower-tiered drug (only two percent switched in the comparison group); and 48 percent of patients using a tier-three statin switched to a lower-tiered statin (eight percent made the change in the comparison group). "This study shows that the devil is in the details when trying to predict the effects of a formulary change," said Huskamp. "Sizeable copayment increases could have worrisome effects." The HMS and Medco Health Solutions team that collaborated on this study are currently conducting another study that looks at how retirees and older employees are affected by similar changes. The study was supported by the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization program, the National Institute of Mental Health, and the Agency for Healthcare Research and Quality. --Nicole Giese and John Lacey