Switch to Generic CV Meds in Medicare Could Save Half a Billion

Patrice Wendling

December 09, 2021

Although brand-name medications make up only a fraction of cardiovascular prescriptions in Medicare Part D, switching to generic alternatives could save an estimated $641 million each year, a new study suggests.

Patients could save approximately $135 million per year by substituting a brand-name drug with the lowest-cost generic equivalent, even after controlling for cash rebates available for some branded drugs, researchers report today in Circulation: Cardiovascular Quality and Outcomes.

"The patient savings are really the story here," senior study author Alexander Sandhu, MD, Stanford University School of Medicine, California, told theheart.org | Medscape Cardiology.

"There's so many areas where there's financial toxicity in healthcare and this is one very easy situation where there's really no trade off, where we can reduce patient out-of-pocket costs and the financial toxicity of their care," he said. "I think it's really critical that the healthcare system find as many ways as possible to facilitate that."

He noted that several studies have shown generic substitutes have efficacy similar to brand-name options. Although they account for a large portion of annual drug spending, previous analyses haven't focused on cardiovascular drugs and potential savings from increased generic substitution.

The investigators, led by Iris Ma, MD, also from Stanford, examined medication fill and cost data for 169 cardiovascular medications prescribed in 2017 for Medicare Part D. This included antiarrhythmics, anticoagulants, diuretics, antihypertensives, lipid-lowering therapies, pulmonary hypertension therapies, and other antihypertensives, such as combination therapies. In all, 122 medications were brand-name drugs, of which 90 had a generic alternative or could be replaced with individual generics.

The results show that $22.9 billion was spent in 2017 on cardiovascular drugs in Medicare Part D. After adjustment for rebates, total spending was $19.1 billion, which included $4.2 billion in costs shouldered directly by Medicare beneficiaries.

Roughly half, or $11 billion, was spent on medications available in both brand-name and generic options.

Although only 2.4% of medication fills were for brand-name drugs, they made up 21.2% of total Medicare Part D spending.

Medicare patients paid $330 million in cost-sharing for the substitutable brand-name drugs, the authors note. For 89% of branded drugs, the average cost-share was lower for the generic version. They estimated that switching to a generic medication would cut patient cost-sharing by $135 million.

The top five drugs with the highest potential cost savings with greater generic uptake were: ezetimibe, rosuvastatin, atorvastatin, olmesartan medoxomil, and ezetimibe/atorvastatin. In a sensitivity analysis, use of the generic versions of ezetimibe and rosuvastatin, first introduced in 2016, would lead to $78 million in savings in 2018.

Pattern Variations

The researchers also reviewed variations in prescribing patterns at the state and clinician level. New Jersey, New York, and the District of Columbia had the greatest potential savings from greater uptake of generic formulas. Generic fill rates, however, were relatively similar across states with and without laws that mandate generic substitution for therapeutic equivalents.

Data from 418,836 prescribing physicians suggest that the potential cost saving was relatively similar across cardiology, internal medicine, and internal medicine subspecialties. More than 50% of the potential savings, however, was attributable to a minority (8.2%) of clinicians with 10 or fewer fills for substitutable cardiac drugs.

"Clinicians who rarely prescribe a drug might not necessarily know that there's a generic equivalent," suggested Sandhu.

He noted that systems-level interventions, such as defaulting the electronic health record to display only generic-equivalent options, have been shown to increase generic prescribing rates. Pharmacies and payers could also reach out to patients directly to encourage substitution by promoting reduced out-of-pocket costs. Real-time feedback from payers regarding brand-name utilization with peer benchmarking may also nudge this minority.

"But even outside that subset that prescribe a drug really rarely, we still see that there is a subset of clinicians that have higher brand-name prescribing rates and it's unclear to me whether that reflects something to do with their patient cohort and the preferences of their patients, which might be reasonable, or whether it represents skepticism or doubts about generic equivalents," he said. "I think there's a lot of possibilities and it's unclear from the data we have, why we have that concentration."

Skepticism Over Generics

Concerns about the safety and efficacy of generics, largely imported from China and India, may be big driver of generic drug hesitancy among clinicians and patients alike, Harry Lever, MD, a cardiologist at the Cleveland Clinic and a vocal critic of American oversight of foreign drug manufacturers.

"If you want, you can search it out and see that a drug comes from China or India but, the fact of the matter is, you don't know about the quality," he told theheart.org | Medscape Cardiology. "There are numbers of companies that are horrible."

The widely publicized recalls in 2018 and 2019 of generic angiotensin-receptor blocker medications contaminated with potential carcinogens has only heightened concerns.

"What you have to think about is what does it cost to have someone readmitted to the hospital when the diuretic doesn't work? Because if the diuretic doesn't work, the hospital under Medicare has to pay a fine back to Medicare if the patient is readmitted within 30 days," Lever said. "So, it's not necessarily saving money."

Sandhu agreed that skepticism about the equivalence and safety of generic medications is a potential barrier.

"Generics afford an incredible opportunity to reduce the financial toxicity of drug costs and to improve the equity of care that we provide by having low-cost, affordable options. But I think it's incumbent that we have the data to demonstrate safety and that involves continued close FDA surveillance of generic drugs."

The authors note that they didn't have data on whether the clinician indicated "dispense as written" to better understand the mechanism for lack of generic substitution. The study also did not account for differences in average doses, included generic substitutions even when they were more expensive than brand-name medications with rebates, and was limited to Medicare Part D prescription plans, which only includes adults older than 65 years.

Sandhu is supported by a grant from the National Heart, Lung, and Blood Institute and is a health policy consultant for Acumen. Coauthor Rebecca Tisdale, MD, MPA, is supported by the VA Office of Academic Affairs Advanced Fellowship in Health Services Research. The other authors and Lever report no relevant financial relationships.

Circ Cardiovasc Qual Outcomes. Published online December 9, 2021. Abstract

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