Post–Myocardial-Infarction Medications with No Copayments

Patients in the United States with acute myocardial infarction are most often prescribed a medication regimen at discharge from the hospital. However, gaps in care can occur following discharge, due mainly to either a failure to fill the initial prescription or increasingly poor adherence over time. Underuse of medication occurs due to various factors, among them out-of-pocket costs. One third of Americans report underuse or discontinuation of medications because of out-of-pocket costs. Among patients with insurance, adherence rates correlate with the comprehensiveness of coverage. Studies have shown that eliminating these costs increases the use of targeted medications, but the effect of the strategy on health outcomes and spending has not been well documented. Researchers recently conducted a study to test the hypothesis that eliminating out-of-pocket costs for evidence-based therapies may encourage medication adherence, reducing the rates of preventable cardiovascular morbidity and mortality. The results of the MI FREE (Post-Myocardial Infarction Free Rx Event and Economic Evaluation) trial were reported online in the New England Journal of Medicine [10.1056/NEJMsa1107913]. Inclusion criteria included receiving medical and prescription drug benefits through Aetna and having been discharged from the hospital with a principal or secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 410 (except when the fifth digit was 2) and a 3- to 180-day length of stay. Exclusion criteria included enrollment in a health savings account or ≥65 years of age. Of the 6768 potentially eligible patients, 913 were excluded because their plan sponsors declined to participate. The primary outcome was the first major vascular event or revascularization. Secondary outcomes included rates of medication adherence, total major vascular events or revascularization, the first major vascular event, and health expenditures. Patients were randomized to full prescription coverage (1494 plan sponsors with 2845 patients) or usual prescription coverage (1486 plan sponsors with 3010 patients) for all statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs). Randomization to a study group occurred a median of 49 days after hospital discharge. The baseline characteristics of the patients were similar between the 2 groups. Average age was 54 years, 75.6% were male, and >50% had filled prescriptions for the study drugs prior to hospitalization. Of those who filled prescriptions between the time of hospital discharge and randomization, average copayments were similar in the 2 groups. Rates of adherence in the usual-coverage group were 35.9% for ACE inhibitors or ARBs, 45.0% for beta-blockers, 49.0% for statins, and 38.9% for all 3 medication classes. Adherence rates were increased in the full-coverage group by 5.6 percentage points (95% confidence interval [CI], 3.4-7.7) for ACE inhibitors or ARBs, by 4.4 percentage points (95% CI, 2.3-6.5) for beta-blockers, by 6.2 percentage points (95% CI, 3.9-8.5) for statins, and by 5.4 percentage points (95% CI, 3.6-7.2) for all 3 medication classes (P<.001 for all comparisons). The odds of full adherence to the study medications increased by 31% to 41% (P<.001). The rate per 100 person-years of the primary outcome of a fatal or nonfatal vascular event or revascularization was 18.8 in the usual-coverage group, compared with 17.6 in the group with full coverage; the difference was nonsignificant. There was a significant difference between the 2 groups in prespecified secondary outcomes. Rates of total major vascular events or revascularization were reduced by 11% in the full-coverage group (hazard ratio [HR], 0.89; 95% CI, 0.80-0.99; P=.03). The HR for the first major vascular event was reduced by 14% (HR, 0.86; 95% CI, 0.47-0.99; P=.03). For individual components of the composite outcomes, the elimination of copayments led to significant reductions in the rate of stroke (HR, 0.69; 95% CI, 0.50-0.96; P=.03) and nonsignificant reductions in the rates of myocardial infarction or unstable angina and congestive heart failure. Eliminating copayments was not associated with a significant difference in the rate of revascularization. In the group with full coverage, there were significant reductions in out-of-pocket spending during follow-up for both prescription drugs and nondrug medical services (relative spending, 0.70; 95% CI, 0.65-0.75; P<.001; and relative spending, 0.82; 95% CI, 0.72-0.94; P=.005; respectively). There was a corresponding increase in pharmacy spending by insurers (relative spending, 1.32; 95% CI, 1.14-1.52; P<.001). In the full-coverage group, mean total spending was $66,008 compared with $71,778 in the usual-coverage group, a nonsignificant difference. In conclusion, the researchers summarized by noting that “the elimination of copayments for drugs prescribed after myocardial infarction did not significantly reduce the rates of the trial’s primary outcome. Enhanced prescription coverage improved medication adherence and rates of first major vascular events and decreased patient spending without increasing overall health costs.”