Tiered Plans: Threat or Promise

Today’s Managing Health Care Costs Indicator is 1.5x

Monday’s Boston Globe had an article on page one (“top of the fold”) on tiered health plans.  The title was “Tiered health plans cutting costs, restricting options.”    The authors tried to be even-handed – but stories with narrative force are more compelling than some dry statistics.  It’s hard to come away from the article with a positive feeling about health plan network options that charge patients more for care at hospitals and providers with higher prices.

The focus of the article is Glenn McCarthy, 48, who was found to have prostate cancer.  Faced with a potential month-long wait to have surgery done at a community hospital ($150 cost share), he chose to have the surgery at an academic medical center ($1000 cost share).  His total out-of-pocket liability ended up not being a thousand dollars, but $4500 because he had a series of complications that led to additional cost sharing.   He and his wife are now struggling to pay this off, and their insurer has denied their appeals.

Enrollment in narrow network or tiered plans has increased sharply in the last few years.   The Massachusetts Group Insurance Commission, which purchases health insurance on behalf of state and governmental employees and retirees,  offered a three month employee “premium holiday” to encourage state workers to choose narrow network plans this year, and 10,000 made the move.

Employers have found that when overall cost of care has increased but they feel cannot afford to raise the employer contribution to this, they can

• Raise employee contributions
• Lower the benefit level (raising member cost sharing across the board)
• Raise cost sharing for providers who have very high prices. 

The last option is attractive because it could encourage some patients to move to more cost-effective providers, as well as encourage providers with high allowed prices to lower these prices. That’s happened in California when CalPERS, which covers state and other governmental employees and retirees started using ‘reference pricing’ for knee and hip replacements.  Some hospitals with allowable fees in excess of the reference price renegotiated their rates to avoid losing patients.

Tiered networks that are based on price alone could actually destroy value by directing patients to hospitals or providers of lower quality.  Most of the available tiered plans use some form of quality ranking to be sure that high quality providers are available within the lower cost tier.

Clearly, tiered networks have the attention of the more expensive providers:

“[Tiered Networks] present one of the greatest threats to access that there is in the Commonwealth right now,’’ said Dr. James Mandell, chief executive of Children’s Hospital Boston.

Many would say that the greatest threat to access is high cost – not health plans that offer lower premiums and a choice of paying higher cost share to get care at Children’s, which is very expensive compared to comparable hospitals.  How expensive?  The Attorney General reported that risk adjusted total medical expense at Children’s was among the three highest in Massachusetts for all three major health plans – over 1.5x the least expensive provider in BCBSMA and Tufts, and over 1.9x in Harvard Pilgrim. 

As I’ve noted before, increase in unit cost is a major problem in Massachusetts, and is the major factor making health care in the US more expensive than in other developed countries.

Clearly,  with huge disparities in cost and without clear correlations with quality, efforts will continue in Massachusetts to rein in higher allowed prices.   Tiered networks are a market lever to try to reduce the price at the highest cost facility. 

There are alternatives.  Former Massachusetts governor Mike Dukakis spoke earlier this week at Harvard School of Public Health and said

If we paid a little attention, it might be a good idea, to the experience of other countries around the world who are doing this and who, for some reason, seem to be able to provide rather good health care to their people at half the cost we do -- whatever the siltstone, whether it’s Australian medicare or a multi-payer system in Germany or an essentially privatized system in Switzerland -- every one of them regulates cost, without exception…Now don’t get me wrong. Nobody loves having to regulate. We had something called the rate-setting commission when I was governor... We treated hospitals as public utilities. They couldn’t raise their rates a nickel unless they went to the rate-setting commission. We certainly didn’t have these huge disparities between what Partners gets and what the BI gets. Wouldn’t allow it. So, we’ve got to get on with the business of regulating costs. 

I’m guessing that we’re likely to continue preferring market approaches to price disparities, so tiered networks will continue to expand.   Efforts to reintroduce price regulation continue to heat up as well.

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Obesity Reduced by Lifestyle Intervention

Today’s Managing Health Care Costs Indicator is 38.2%

Obesity isn’t easy to treat.

We all know that even people who reduce their caloric intake by 30,000 calories often don’t lose 10 pounds, and recent research shows that hormonal changes subvert our efforts to become svelte (or even to become non-obese). 

Two studies published in the Thanksgiving New England Journal of Medicine show surprising efficacy of lifestyle coaching to help patients lose weight.  In both studies the interventions were built around the primary care practice (not the insurance company), and both studies were part of an ambitious 24-month three center study funded by the National Heart Lung and Blood Institute. 

The NEJM published the Johns Hopkins study, done in collaboration with Healthways.  This study showed losses of 0.8kg (control group), 4.6kg (telephonic coaching only), and 5.1kg (in-person coaching).  A striking 38.2% of people in the telephonic coaching group lost more than 5% of body weight.  That number was 41.4% in the in-person group, even though participants only attended a small fraction of the recommended in-person sessions. Persistance with the web portal was also high.

NEJM also published the University of Pennsylvania study, which compared usual care with brief and enhanced brief lifestyle coaching.  Enhanced included treatment with medications and free provided low calorie meals.  The UPenn study showed weight loss of 1.7kg (usual care), 2.9 kg (brief coaching), and 4.6kg (enhanced coaching).  Again, a striking portion of the participants lost more than 5% of their body weight (usual 21.5%, brief 26%, enhanced 34.9%).

These are impressive studies.  They were difficult to carry out, although they were well funded.  Both studies had low dropout rates.  It will be important that the researchers also publish the results of the third study – to see if the results are consistent.   Even so, this reporting is much less subject to publication bias than most of what we see in the wellness literature.   The studies are also small – only about 400 people in each three-arm study, so under 150 in each of the treatment groups.  It’s also striking that the participants in usual care lost so much weight, since this is quite contrary to the usual practice experience.

Obesity is clearly one of the major causes of future preventable death and adverse health care outcomes – and it’s heartening to see credible evidence of efficacy of the coaching intervention.

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Statins Remain Cost Effective, Not Cost Saving

Today’s Managing Health Care Costs Indicator is $169,549

Click on image to enlarge.  Source below

Statins are enormously effective drugs that, along with a decrease in cigarette smoking, have been responsible for a huge decrease in the incidence of cardiac death, especially in young men.    Statins were shown to be effective  at lowering mortality in 1994  in the 4S study (Scandinavian Simvastatin Survival Study).   This study was reevaluated in 1996 to look at changes in hospital costs, and the saved hospitalizations in the treatment group covered 88% of the cost of simvastatin in the high risk group.  

Simvastatin has been a generic medication for a few years, and atorvastatin (Lipitor) is going generic this coming month. Have we finally reached a point where the use of statins is not merely cost-effective, but is actually cost-saving?

Even with dramatic declines in the acquisition cost of the statin medications, though, treatment in this simulation done in BMJ this past March was not cost-saving in any cohort.  The cost of a Quality Adjusted Life Year for a 55 year old man with a 5% ten year risk of a heart attack was 125,544 euros (or  almost $170K)

Harvard Link

Non-Harvard Link  

As you can see from the graphic – the cost to save lives with simvastatin was actually quite modest in many instances - especially over the longer time horizons. For instance, it cost only 5394 Euros for each QALY for 55 year old men at a 30% risk for a vascular event over the following 10 years. Still, not a single simulated group gained QALYs with LOWER costs. 

We don’t save money by using even generic statins for primary prevention of heart of vascular disease.   We only gain good health outcomes for a reasonable cost -- which doesn’t seem to me to be a bad outcome at all.

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Avastin: Great hope, or futile care?

Today’s Managing Health Care Costs Indicator is $7 billion

That’s the annual revenue that Genentech gets from sale of Avastin.

Avastin is the first of the anti-angiogenesis medications – which we all hoped based on mice studies would kill cancers by starving them of blood supply.  It works – but not nearly as well as we hoped. An early study suggested that the drug might prolong life in those with breast cancer, but subsequent studies have actually shown that the drug offers no benefits, but does come with severe and even life-threatening side effects.

The FDA advisory panel voted 6-0 to remove the breast cancer treatment indication from this drug, which costs $90,000 per year.  The drug remains on the market – and continues to be recommended for the treatment of other cancers.   CMS will continue to pay for the drug when prescribed for breast cancer despite the adverse evidence, as will just about all private insurers. Those that announce they will not pay for Avastin are subject to blizzards of emails and protests and appeals.

Here are two voices on this issue. The first, yesterday’s Wall Street Journal editorial:

…There's no denying that [The FDA decision] decision is an awful turn for anticancer progress and innovation, and especially for the women who may lose a treatment option in the time they have left to live.”

The second, Joe Nocera today in the New York Times:

Here is an enormously expensive drug that largely doesn’t work, has serious side effects and can no longer be marketed as a breast cancer therapy. Yet insurers, including Medicare, will continue to cover it...If we’re not willing to say no to a drug like Avastin, then what drug will we say no to?

 We won’t solve the health care cost crisis if we continue to cover expensive, ineffective drugs.   It’s hard for me to see this as heavy –handed government overreach.  Forget about the cost –the medicine appears to make the lives of terminally ill women worse.  Giving physicians and patients the information they need to make the best decision seems like a good role for the FDA. 

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The Stakeholders Would Just Plotz!

There’s been some jubiliation in Massachusetts with the Commonwealth Fund report that insurance here is no longer the most expensive in the country.  My colleague Nancy Turnbull, has a great post in the Commonhealth Blog entitled “Stop Kvelling, We Still Need Aggressive Action To Halt Rising Premiums.”  She points out that any jubilation is misplaced – our health care premiums have gone up rapidly – just not as rapidly as a handful of other states.  In fact, by many measures our health insurance remains the most expensive in the country – which means the most expensive on the planet.  

The problem, of course, is that halting the rise of health care premiums will create hardship in the state’s growth industry – health care.  In fact, most of the proposals to lower health care costs make the stakeholders want to plotz!

The commentary is great - and it’s topped off by a prolonged metaphor that left me chuckling. Nancy’s response to a question about why politicians don’t address the impact of rising  health care costs on small business:

There's clearly a great fear of "killing the golden goose" of health care in Massachusetts.  The problem is that the golden eggs are not distributed fairly although we're all paying for the feed, and the price of over-feeding the goose is a starvation diet for  others (including public health).  Sort of like the health care equivalent of foie gras.

(Kvell is a great Yiddish word that means something approaching gloating –but it’s virtuous. We kvell when our kids make deans list.  Plotz is to be so annoyed that you could faint with anger.  When someone threatens to take away what’s mine, I could just plotz.

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Self Referral: Another Installment

Today’s Managing Health Care Costs Indicator is 215%

Nuclear exercise stress tests are generally not recommended as “routine followup” after coronary revascularization.   However, cardiologists who were paid either professional fees (to read such tests) or who actually owned the equipment and were paid both technical and professional fees were 1.6-2.3 times more likely to order such tests, according to an article in last week’s Journal of the American Medical Association.  The same pattern was found for stress echo tests, which are performed much less frequently.

The authors looked for patients who were 90 days out from bypass or angioplasty, and found imaging tests performed within 30 days of a cardiologist office visit. They excluded patients with an intervening cardiac event.   This was from a large database of commercial claims, and the patients were on average between 54 and 55.

The authors note that the frequency of these tests in cardiologist offices increased 215% between 1998 and 2006, 181% in other physician offices, and only 32% in radiologist offices.

The physicians ordering these tests no doubt believed they were necessary.  Self referral has again been shown to lead to higher utilization and higher costs.  It also appears to be associated with lower levels of practicing evidence-based care.

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Ezekiel Emanuel and Health Care Costs

Today’s Managing Health Care Cost Indicator is $26 billion

Ezekial Emanuel, noted oncologist, ethicist, recent presidential advisor and brother of Rahm, finished a four-part article in the Times Sunday Review about health care cost control.  It’s well worth reading.

Post One: Spending more doesn’t make us healthier reviews the fact that we aren’t getting better health or health care for the extra dollars we spend in the US -  and these health care dollars crowd out other meaningful uses for those dollars

Post Two: Less than $26 billion – don’t bother makes the point health care costs go up over $100 billion a year. He reasons that if a potential intervention wouldn’t save at least 1% of costs – we should put our efforts into other initiatives.  This threshold is important in terms of setting priorities.

Post Three: Billions wasted on billing points out that the administrative costs of our complex and fragmented system are enormous, and he uses his own experience with minor surgery as an illustrative example.   He doesn’t suggest fixing the fragmented and complex system – merely standardizing transactions.

Post Four: Saving by the Bundle suggests that there are huge potential savings associated with better coordination of care of the sick – and they’re the ones whose medical expenses are driving cost increases. 

I recommend the series – it’s thoughtful and provocative

It’s also missing an important element of our health care cost crisis.

There is no acknowledgement that the underlying reason why our system costs dramatically more than Canada or the European countries is not even administrative costs or poor coordination.  It’s that we have very high prices compared to these other countries.    Here are some charts from Massachusetts about this topic, here’s a reference to a September Health Affairs article on the issue of unit cost, and here is a post that gives links to International Federation of Health Plan data and the original 1993 Anderson/Reinhardt article “It’s the Prices, Stupid?

There are plenty of reasons why stakeholders don’t want to talk about the unit price issue.

• Providers are being paid these high unit prices. It’s easier to talk about someone else’s utilization than one’s own price!
• Pharmaceutical companies like high unit prices just fine
• Health plans are a bit embarrassed that they’ve been unsuccessful at controlling unit costs
• Health plans and other parties have a profitable business in lowering utilization
• Government wants continued growth in health care sector jobs 

Movements toward narrow networks and reference pricing will be future counterbalances to high prices (and high variation in prices from facility to facility).  If we can better control unit prices, we can lessen medical inflation substantially.

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Hospital-Health Plan Contractual Feud Goes Public

Today’s Managing Health Care Costs Indicator is 3%.

Dear Business Partner:

Tufts Medical Center and NEQCA Are Terminating from Our Network
The single biggest piece of health care spending is what doctors and hospitals are paid to care for patients. About 90 cents of each premium dollar goes toward medical services. When these costs increase, premiums go up. In our meetings with hospitals and doctors over the past several months, we made it clear that we want to pay them the reasonable costs of caring for our members, while being responsive to the community's expectations about affordability.

Regrettably, both Tufts Medical Center (TMC) and the New England Quality Care Alliance (NEQCA), an organization that represents doctors, have told us they do not want to participate in our provider network at the rates we offered to pay. We still hope to reach an agreement with these providers. However, if we do not, these providers will be terminating their HMO Blue^®, HMO Blue New England^SM, and PPO contracts with Blue Cross Blue Shield of Massachusetts, effective January 17, 2012. These providers will be terminating their Indemnity contracts effective March 31, 2012.

With these words, Blue Cross of Massachusetts set in motion the latest salvo in provider-health plan contractual wars. Tufts Medical Center and its affiliated physicians care for  somewhere between 88,000 (WBUR) and 200,000 (Boston Herald) Blue Cross Blue Shield members – so this is a big deal. 

It’s a good opportunity to review some of the underlying issues in the intricate dance of health plan - provider contracting.  

1. Why do these contract disputes become public in the fall?

Fall is open enrollment season – when many patients have the option to change their insurance plan.   Providers in general feel that they have a higher amount of leverage at the time when health plans worry that members will switch to competitors.

However, many members now have only a single insurance health plan available through their employer, so the opportunity to shift from BCBSMA to a competitor is much lower than a decade ago. 

2. If Tufts Medical Center leaves the Blue Cross Blue Shield network, will that lower health care costs?

Click image to enlarge 

Not likely.  Tufts Medical Center is paid substantially less than other academic medical centers, and even less than some community hospitals.   See this graphic from the recent Attorney General Report.  (Find Tufts under “New England Quality Care Alliance” about 1/3 from the left on the graphic below).  Here’s a link to my post from June when this report was released, which shows Tufts (as NECQA) always below the middle of the pack in terms of expense. Here’s a link to the AG report. Ironically, this type of transparency might have encouraged Tufts Medical Center to demand higher rate increases. CEO Eric Beyer says Tufts asked for a 3% increase.

However, BCBSMA wants to send a signal that it is serious about not offering large rate increases – so this public negotiation could strengthen the health plan’s hand in private negotiations with other delivery systems.

3. Who goes public with a contractual dispute?

Usually, parties go to the public when they feel they have more leverage.  On the other hand, BCBSMA states that it was legally obligated to go public because it must inform clients and members 60 days before a provider leaves its network.

4. Who has more leverage in this negotiation?

I have no inside information.   Generally, asymmetry of influence determines leverage.  BCBSMA could easily represent a fifth of Tufts Medical Center’s income (if Medicare represents about half, and considering that BCBSMA represents almost half of the commercial market), while Tufts Medical Center represents only about 2% of hospital discharges for the state – so is unlikely to represent more than 3-4% of total BCBSMA business.  (Data from 2006 – most recent I could quickly find)

Provider leverage is diminished by the movement from HMOs (where patients have no coverage outside the network) to PPOs (where patients can go outside the network but must pay deductible and coinsurance).  There is increasing acceptance of narrow networks – which also diminishes provider leverage.  The demand for all-inclusive provider networks in the 1990s helped gain many hospital systems large increases during that decade.

The total amount of the disagreement is reported by the Boston Globe as $11 million in a $1.2 billion contract.   That’s not much – so I’m guessing that 88,000 (or 200,000) patients will not have to scramble for new providers in January.

Uwe Reinhardt has a commentary this month in Health Affairs suggesting that we should do all-payer rate negotiation, which would mean that each provider would be paid the same for similar services.  I'll be talking about that idea in a future post. 

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Three Graphs Tell the Story: It's the Prices!

These three graphs are from the Recommendations of the Massachusetts Special Commission on Provider Price Reform. released last week.  For anyone who wonders if unit cost is a substantial portion of the cause of health care cost increase in Massachusetts, these data paint a clear picture.

The entire report can be accessed at this link.

Click on any image to enlarge it.

Jon Kingsdale, the founding Executive Director of the Connector Authority in Massachusetts, will be talking about the role of government in health care costs in our HSPH course on Wednesday.  Here's a link to a Health Affairs blog post of his from July on the problem of "costitis."

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Pfizer Maneuvers to Delay Access to Generic Lipitor

Today’s Managing Health Care Costs Indicator is $106 billion

Saturday’s New York Times documented efforts Pfizer is making to  thwart conversion from brand name Lipitor to generic atorvastatin.  Pfizer is promising huge discounts on brand name Lipitor if the Pharmacy Benefit Managers (PBMs) block coverage for generic atorvastatin for six months. 

Here’s what this will do:

1)     Patients will continue to pay the higher ‘brand name’ copay or coinsurance, rather than paying the lower cost share for a generic

2)     Employers will in general pay more – although if the Pfizer discounts are deep enough the incremental payment could all be absorbed by increased patient cost-sharing

3)     Enhance profitability for PBMs, which will take a share of the ‘discount’ offered by Pfizer as detailed in employer contracts.   PBMs usually make more money with generics – but Pfizer’s move would upend that situation for Lipitor for the next six months.

4)     This will be a financial body blow to the two generic manufacturers, Ranbaxy and Watson, who have a 6 month window of semi-exclusivity when they can sell their generics for a discount compared to Lipitor.  Six months later, when all generic manufacturers are able to produce and sell atorvastatin, the price will collapse, and there will only be a small profit opportunity.

New generic medications, in general, sell for about 20% less than the brand name equivalent during the 6 month semi-exclusive window.  At that point, it’s likely that the price of generic atorvastatin will decline to just a little bit more than generic simvastatin, which is now sold at WalMart and other pharmacies for as little as $4 per month.   Lipitor now sells for $160 for a one month supply (drugstore.com, 20mg). 

Pfizer has earned a quarter of its revenue, or $106 billion, from Lipitor over the last decade. 

The manufacturers willing to run the legal gauntlet to challenge Pfizer’s patents to be the first to offer generic equivalents must see a substantial payoff, otherwise we would have a de facto six month extension for drugs going off patent. Delaying availability of generics could cost us billions.

More important than the higher prices consumers or employers will pay is that Pfizer’s actions threaten the profitability of the initial generic manufacturers. That could prove the most expensive result – and employers and regulators should look at this deal very closely.

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Steward Shops for Docs

Today's Managing Health Care Costs Indicator is $3 million

It's no surprise and no secret that hospitals are buying up and affiliating with physician practices.

This could lead to some social benefits.  Hospitals have the capital and expertise to make the big IT investments necessary to bring physician practices into the 21st century.   Organizations that bring together hospitals and their associated physicians can better accept bundled payment, and even capitation.  More integration could certainly lead to better coordination of care.  Some even suggest it could lead to cost savings. 

Today's Boston Globe highlights a northeastern Massachusetts group of 150 physicians, who represent most of the medical staff of Anna Jacques Hospital of Newburyport.  The physician group just announced it would sever its ties to Beth Israel and affiliate with Steward, the for-profit hospital system which has promised to be the low cost high value delivery system in the state.   Steward is also seeking to purchase delivery systems in Rhode Island and other states.

Both sides have lawyered up, and The Incidental Economist suggests that Steward is likely to prevail, and I agree. 

What will this do to the cost of health care?

Steward said that the physicians could earn $3 million more through their contract compared to their potential earnings through the Beth Israel contract.   Steward is also said to have promised to cover any losses under a large global budget (capitation) contract with Blue Cross of Massachusetts. 

If any delivery system is promising higher physician income, and no “downside” risk without new processes to decrease resource use in the system, this will lead to either dashed physician hopes or increased health care costs.

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Disruptive innovation: United offers on-line hearing tests

This week's American Medical News, an AMA publication, notes that a subsidiary of United Health Care, hi Health Innovations, is offering an online hearing test, which will allow users to order hearing aids without a physician visit.

No surprise that the AMA opposes this move.   It's not in the best financial interest of physicians for their patients to be able to get hearing aids without a physician visit.  The costs of obtaining a hearing aid this was a estimated to be as much as 3/4 less than comparable devices purchased through conventional channels.

This fits well with some of the bolder ideas from the Connected Health Symposium last month.   The new word for me there was "de-skilling," replacing a highly trained professional with a highly automated process.   

UHC might not succeed with this venture, especially since trust in the Internet (And high speed access) are higher with a younger demographic that those with a higher rate of hearing loss.  But even if this fails, there will be more attempts to replace physicians with hardware and software, and this type of innovation can bring cost saving without sacrificing quality.

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“Government Study Debunks Stroke Treatment”

Today’s Managing Health Care Cost Indicator is $20 million

It’s not often you see such a headline in the New York Times.  The paper is reporting on a paper published in JAMA that showed those with history of “prestroke” with proven blocked neck arteries who received surgery to increase brain blood flow had no fewer strokes than those who were treated without surgery.  The study was stopped early when there was not even a trend of improvement among those treated, and far more early strokes.

A JAMA editorial writer wrote that “doctors liked new technology, were paid well to use it and tended to believe in what they were doing, even without data.”

The thing is –the procedure worked!  Those who had the bypass surgery did have greater brain blood flow.  Unfortunately, the intermediate outcome measure (more brain blood flow) was not especially correlated with the desired outcome measure (fewer strokes.)

This is the kind of effectiveness research we need so that we spend precious health care dollars on services that genuinely improve health,  and the kind of research that only the government is likely to fund.  It’s a small investment –since if 24,000 Medicare recipients a year would have been candidates for this operation, the total cost if it was widely adopted would have approached a billion dollars.   But who besides government would spend $20 million to study this?  Alas, funds for the NIH are being cut,  and this kind of important research will be threatened.

There were two reports in the NEJM this past week also reflecting the importance of large, multi-year, government-funded studies of interventions that seem like a good idea, but had never been rigorously studied.  Alas, both also showed little of the financial savings promised by boosters.

RTI reported on the Medicare Health Support trial, which was terminated in 2008 when none of the disease management companies appeared to be on target to save as much money as their interventions cost.   The study is flawed, of course, since the information available to those companies about the “at risk” Medicare beneficiaries was often available far too late.  Still, most of us deeply believed that these programs would be more successful at preventing hospitalizations in the Medicare population, a target-rich environment.   


The other is a commentary about the Physician Group Practice Medicare demonstration project.  The groups improved quality substantially.  However,  high hopes of dramatic declines in health care spending were not realized.  2 of the 10 groups had savings of over 2% at one year, and half had savings of over 2% at five years.  These were all groups with robust infrastructure, committed leadership, and cultures of prudent use of resources.   This shows that creating Accountable Care Organizations from physicians in practices that are currently fragmented and disorganized will be very hard indeed.  

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Combination Drugs: At What Price?

Today’s Managing Health Care Costs Indicator is $167.40

I’m a devoted reader of the Medical Letter – a nonpartisan, nonprofit biweekly newsletter on drugs that is not supported by pharmaceutical advertising.

This week’s issue highlights a new medicine, Duexis, which is a combination of a high dose of ibuprofen (800 mg, Advil or Motrin) and a high dose of famotidine (26.6mg, Pepsid).  These medicines make sense together – ibuprofen causes a substantial amount of GI upset and some ulcers, and famotidine can prevent these complications. 

All the elements of this medicine are available over the counter – and they’re all available from multiple different generic manufacturers.  The cost of a month of this therapy – using generic OTCs, would be well under $30, and would allow more dosing flexibility. (Many patients experience relief from ibuprofen 600mg, and famotidine is generally not prescribed as more than 40mg a day). 

The cost of the combined pill?  $167.40 per month.

There are compelling reasons to put medicines together – and a single “superpill” to address cardiovascular risk (combining aspirin, angiotensin converting enzyme inhibitor, and statin cholesterol medication) would be an enormous boon. 

There are good reasons not to prescribe Duexis, though:

1)     It’s far too expensive

2)     The fixed doses are convenient but not clinically optimal

The manufacturer has priced this medication with reference to the cost of brand name antiinflammatories and antiulcer medications – but it makes better sense to value this medication with reference to generic/OTC medications.

I’m hopeful that health plans and pharmacy benefit managers will choose not to increase the cost of health care by providing coverage for this medicine.

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