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Medical insurance shapes TNF-inhibitor prescribing



Jan 24, 2006



Janis

Philadelphia, PA - In the US, patients whose medical insurance pays

for a particular drug rather than another in the same class are more

likely to get the covered drug. In the case of TNF inhibitors and

rheumatoid arthritis (RA) patients receiving Medicare, this has led

to greater use of infliximab (Remicade, Centocor) than etanercept

(Enbrel, Wyeth/Amgen), even though total costs associated with

infliximab are greater, Dr Esi DeWitt (Children's Hospital of

Philadelphia, Pennsylvania) reports in the January 9, 2006 issue of

the Archives of Internal Medicine [1].

Using an observational cohort study of 1663 RA patients prescribed

either etanercept or infliximab after enrollment in the National

Databank for Rheumatic Diseases, DeWitt and colleagues found

that " patients with public insurance were 30% more likely to receive

infliximab than those who were privately insured (p<001). "

Proof that physicians are not oblivious to patients' financial status





Patients with public insurance were 30% more likely to receive

infliximab than those who were privately insured.





That a physician might prescribe a $12 610 drug the patient can get

because it is covered by insurance rather than a $10 159 drug that is

unavailable unless the patient can pay for it from personal funds is

doubtless not a surprise to clinicians. However, the work by

DeWitt et al expands a relatively small number of studies that

reliably document the effect of such financial considerations on

prescribing behavior.

DeWitt found that the etanercept vs infliximab patients

differed on six of eight demographic variables and in eight of 10

disease variables but that stratifying by type of insurance (public

vs private) wiped out the predictive value of those other

differences. In particular, type of insurance plan and demographic

factors remained strong predictors in multivariate analysis. Disease

characteristics were not strong predictors.

The reason for the prescribing difference is that infliximab, which

is given via IV infusion at a hospital or outpatient center, is

covered by Medicare. Etanercept and other injectable drugs self-

administered by patients at home are not covered. This split has been

a source of aggravation to rheumatologists (and probably to patients)

and has been one of the points the American College of Rheumatology

and other professional and patient groups have wanted to see changed.

" Preferential prescribing of infliximab rather than etanercept

provides yet another example of how Medicare's unequal reimbursement

for different treatments affects physicians' choice of therapies, "

DeWitt writes. " The recent Medicare policy of preferential

reimbursement for infusion therapies vs self-injectable drugs

inadvertently may be increasing healthcare costs by promoting use of

the costlier of two equivalent drugs. "

This study was done before the arrival of the new Medicare Part D

outpatient drug benefit for elderly US patients, but the effects

described are likely to have implications both for insurance-company

formulary committees and for physician prescribing. DeWitt

predicts that the impact of Medicare Part D reimbursement on TNF-

inhibitor prescribing is likely to be " modest " in view of the $2850

" doughnut hole " for which patients will still be liable.

In an editorial commenting on this study, Drs Levinson

(University of Toronto, ON) and s Laupacis (Institute for

Clinical Evaluative Sciences, Toronto, ON) note that the difference

documented is partly due to an oddity in the US healthcare system

[2]. Although many managed-care organizations, state Medicaid

programs, and the Veterans Health Administration are using formulary-

development guidelines that include economic cost/benefit analyses,

the US Centers for Medicare and Medicaid Services (CMS) " does not

incorporate such analyses into their funding decisions. "



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