Mandating use of multiple medications ineffective for an indication simply increases expense, an apparently illogical approach—unless the insurance company plans to totally block access to the appropriate medication under any circumstance—with the hope that all involved will give up and the insurance company won’t have to pay for the patient’s treatment.
Some formulary problems derive from insurance company advisors’ lack of familiarity with the pertinent literature. Insurance companies typically deny access to medications that represent combinations. Refusal to allow more convenient forms of medications may superficially seem cost effective, but it makes medical care more complicated. An increase in the number of individual pills or medications a patient must take compromises compliance and increases the risk for erroneous consumption—with associated morbidity and associated increased expenses. Even if those risks and expenses did not outweigh the perceived cost savings, the insurance company refusals are based on the often untested assumption that the response to combination medications is equivalent to the sum of their components.
Case in Point
Arthrotec (the combination product containing misoprostol and diclofenac) exemplifies such irresponsible interference with patient care. It combines (actually coats) a non-steroidal anti-inflammatory drug with an agent (misoprostol) that greatly reduces the ulcer risk. Recall that 1–2% of individuals over age 51 (that age was the lower limit in the pertinent study) are hospitalized (not just acquire) for ulcers every year and that individuals with arthritis often require long-term use of such agents.1,2 Twenty to forty percent of long-term users will be hospitalized.
The combination product’s efficacy in greatly reducing that risk has been clearly demonstrated.3,4 The timing of the outer layer’s (misoprostol) dissolution allows it to prepare the stomach by increasing gastric blood flow, and buffering and reducing acid production at the precise time when the coated diclofenac (the anti-inflammatory component) is exposed. Use of misoprostol alone to prepare the stomach requires timed administration and requires significantly more of the misoprostol to be effective.5 So replacement of the combined product by its components requires the same diclofenac dose, but requires significantly more misoprostol—three ante-meal and one nightly misoprostol dose—to achieve the same reduction of ulcer risk.3-5 Thus, replacement by its components not only significantly complicates the patient’s medication regimen (requiring five or six, rather than one or two pills and special attention to the timing of doses), it actually incurs greater expense. Misoprostol is the expensive component of the medication, and the cost of three or four misoprostol is greater than that of one or two of the combined product. Denying that product not only compromises compliance and patient safety, but actually incurs greater expense, thus making said denial fiscally irresponsible.
Medically & Fiscally Detrimental
When insurance companies were required to spend 93% of premiums on actual healthcare provision, one company then listed its advertising expenses as a healthcare provision cost. Although insurance company formularies possibly may not represent similar behavior, some certainly don’t seem adherent to the scientific and evidence-based approach that defines contemporary medical care and actually work to the detriment of all involved. So when a product is offered by such an insurance company as “for you,” the patient or “for life,” is that representation an oxymoron?
