The True Cost of Focusing on Cost Instead of Cost-Effectiveness

In the latest chapter of cost-control attempts, insurance companies are increasingly enforcing two strategies for patients who are currently on expensive medications: mandating re-authorization of those medications, and requiring that they switch to a “cheaper” therapy. 

In Massachusetts, regulations were recently passed stating that patients should not be changed from stable therapy. This is a great advancement but also raises questions:  What is “stable?” Who gets to decide the definition and the patient’s status? And what happens to patients in places that do not have regulations similar to those in Massachusetts? What are the costs of switching patients whose disease is under good control? And do they really save money if a meaningful number of patients lose progress either because of the delays these policies create or the lack of effectiveness of other treatments?

As a dermatologist who frequently prescribes biologics that are considered “expensive,” my patients’ experience makes it clear that the price of the medication alone cannot be the only factor in defining cost. 

Recently, I had a patient who substantially improved on biologic therapy and was required to switch to a biosimilar. She experienced unusual psychiatric side effects from the biosimilar and despite our appeals, was denied the opportunity to return to the original treatment on which she had been well controlled for years. We were then required to switch her to another therapy, which did not result in improvement and also created a number of adverse events. She nearly required hospitalization and did require three months of FMLA (Family and Medical Leave) because of the worsening of her disease. Ultimately, we were able to get an IV version of therapy, which is a substantially more expensive medication, approved and now she is improved. However, she never should have had to undergo this debilitating and costly experience. 

For the vast majority of patients with chronic diseases, especially inflammatory ones, when they are stable on a therapy and that therapy is withdrawn, their disease returns. Often these patients have already suffered terribly, and finding a stable therapy has changed their lives. When payors consider only the cost of the medication and not the cost and risk to the patient, doctor, and healthcare system, the irony is that not only is this terrible for patient health, it can be more costly in the end. After wasting hours on approval appeals and denials, physicians must work to try to treat conditions that were previously stable, often ending up with costlier treatment when disease returns, sometimes worse than ever before.

Focusing on the cost of drugs alone ignores these risks to patients, the cost to our healthcare system and the cost to society. The true costs include physician and healthcare staff time, with countless hours devoted to appealing denials and navigating different prior approval and appeal systems. While many patients blame insurers for interruptions to care and rising costs (one survey of 2000 American voters found that 47% identified corporate health insurers as the primary driver of rising healthcare costs, and 79% expressed concern about corporate health insurers denying or delaying physician-ordered treatments. There is also a serious cost to the doctor-patient relationship. When a patient is finally stable on a medication and is getting relief from a debilitating condition, being switched to a different medication is confusing and upsetting—their doctor is the one prescribing the medication, and switching them off of a therapy that was working well erodes their trust in their doctor and their health care system.  

At the same time, the doctor loses control over their patient’s care. It is incredibly frustrating to know, through years of practice, research and clinical knowledge that the “cheaper” therapy will not work, but being forced to prescribe it. Doctors also understand that many patients will suffer from the “nocebo” effect: they may believe that switching from a therapy that is working will fail, even if clinically it might not — especially if the patient had tried ineffective therapies in the past. 

It is time for payors to move on from assessing prescription costs in a vacuum to focus on the health of patients who are succeeding on therapy and the overall cost to the patient and the healthcare system of non-medical switching. The new Massachusetts regulations serve as a model and, if implemented as intended, are likely to improve physician satisfaction and effectiveness, reduce administrative costs, and, most importantly, keep patients healthier.

Author bio

Alexa B. Kimball, M.D., M.P.H., is President and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center in Boston, a $1B academic multi-specialty physician organization dedicated to taking care of doctors — so they can take care of people.

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