Sydor Anne M, Rivera Esteban, Popovian Robert
Global Healthy Living Foundation, Upper Nyack, New York, USA.
Pioneer Institute, Boston, Massachusetts, USA.
J Health Econ Outcomes Res. 2024 Nov 27;11(2):154-160. doi: 10.36469/001c.125251. eCollection 2024.
The Inflation Reduction Act's Medicare Drug Price Negotiation Program allows the federal government to negotiate caps for select medications. These price caps may reduce revenue for the pharmacy benefit managers (PBMs) that negotiate the actual price paid for medicines in the U.S. To offset the resulting pressure on their profit margins, it is possible that PBMs would, in turn, increase patients' out-of-pocket costs for medicines with capped prices. The model presented here evaluates how increased out-of-pocket costs for the anticoagulants apixaban (Eliquis) and rivaroxaban (Xarelto) could impact patients financially and clinically. Copay distributions for all 2023 prescription fills for apixaban and rivaroxaban managed by the 3 largest PBMs, CVS Caremark, Express Scripts International, and Optum Rx, were used to approximate current copay costs. Increased out-of-pocket costs were modeled as a shift of all apixaban and rivaroxaban prescriptions to the highest copay tier. The known linear relationship between copay costs and treatment abandonment was used to calculate the potential resulting increase in treatment abandonment. Known rates of morbidity and mortality due to abandoning anticoagulants were used to estimate resulting increases in morbidity and mortality. If the 3 largest PBMs all shifted costs onto patients by moving all apixaban and rivaroxaban prescriptions to the highest formulary tier, Tier 6, patients' copay amount would increase by 482 million for apixaban and 206 million for rivaroxaban. Such an increase could lead to 169 000 to 228 000 patients abandoning apixaban and 71 000 to 93 000 abandoning rivaroxaban. The resulting morbidity and mortality could include up to an additional 145 000 major cardiovascular events and up to 97 000 more deaths. The Medicare Price Negotiation Program could impact patients negatively if it causes PBMs to increase patients' out-of-pocket costs for medicines. Policymakers should closely monitor changes in overall affordability, including all patient out-of-pocket expenditures, for medications in the program. Preemptive measures should be considered to ensure that the most vulnerable citizens are not placed in precarious situations, leading to poorer health outcomes.
《降低通胀法案》中的医疗保险药品价格谈判计划允许联邦政府协商选定药品的价格上限。这些价格上限可能会减少药房福利管理机构（PBMs）的收入，这些机构负责协商美国药品的实际支付价格。为了抵消由此对其利润率造成的压力，PBMs有可能反过来提高患者购买有价格上限药品的自付费用。本文提出的模型评估了抗凝药阿哌沙班（艾乐妥）和利伐沙班（拜瑞妥）自付费用的增加如何在经济和临床方面影响患者。由三大PBMs（CVS Caremark、Express Scripts International和Optum Rx）管理的2023年所有阿哌沙班和利伐沙班处方的共付分布情况被用来估算当前的共付成本。自付费用的增加被模拟为所有阿哌沙班和利伐沙班处方转移到最高共付层级。利用共付成本与治疗中断之间已知的线性关系来计算治疗中断可能导致的潜在增加。使用因停用抗凝药导致的已知发病率和死亡率来估计由此导致的发病率和死亡率的增加。如果三大PBMs都通过将所有阿哌沙班和利伐沙班处方转移到最高处方层级（第6层）将成本转嫁给患者，那么患者购买阿哌沙班的共付金额将增加4.82亿美元，购买利伐沙班的共付金额将增加2.06亿美元。这样的增加可能导致16.9万至22.8万名患者停用阿哌沙班，7.1万至9.3万名患者停用利伐沙班。由此导致的发病率和死亡率可能包括多达14.5万例额外的重大心血管事件和多达9.7万例更多的死亡。如果医疗保险价格谈判计划导致PBMs提高患者购买药品的自付费用，那么该计划可能会对患者产生负面影响。政策制定者应密切监测该计划中药物总体可负担性（包括患者所有自付支出）的变化。应考虑采取预防措施，以确保最脆弱的公民不会陷入不稳定的境地，从而导致更差的健康结果。
