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Vouchers and Heart Meds; Medical Advertising: It’s PodMed Double T! (with audio)

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include paying people to take heart medicines, resecting the esophagus, economic impact of cardiovascular events, and medical advertising.

Program notes:

0:41 Economic impact of cardiovascular events

1:43 Has societal consequences

2:45 Economic burden on people with cancer

3:40 Incentivizing people to take heart medicines

4:40 Gave half a voucher

5:42 Cost wasn’t the entire issue

6:05 Esophagus resection

7:02 Lower incidence of complications with less invasive procedure

8:02 Didn’t compromise survival

8:36 Medical advertising

9:35 $2.1 billion to $9.6 billion increase

10:36 This is a trust issue with patients

11:29 End


Elizabeth Tracey: What’s the long-term impact of having a cardiovascular event on earnings?

Rick Lange, MD: Trends in medical marketing over the last 20 years.

Elizabeth: If you need to have your esophagus resected, what’s the best way?

Rick: And if you reduce medication copay, can you increase medication use in heart patients?

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on January 11th, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I’d like to turn first to the Canadian Medical Association Journal. Sometimes we do cover stories that come out of here. In this case, this was a retrospective analysis of, “Hey, what happens to people if they have a cardiovascular event in the long term with regard to their earnings and employment?” which I think is kind of a soft science thing, but it’s also a really important outcome.

So this study clearly looked retrospectively from 2005 to 2013. They matched hospitalizations for cardiovascular events and income tax returns, and they looked at these folks. They were aged, by the way, 40 to 61 years at the time of the event, and they worked in the 2 years before that happened and were alive 3 years after the event. Basically, the upshot of the whole thing is that there were substantial losses in both employment and earnings that persisted for at least 3 years after the event for people who had these kinds of things happen in their lives.

Rick: Elizabeth, you called it soft science and I appreciate that. This has societal consequences. Oftentimes, we talk about an acute event like a heart attack. We focus on the hospitalization and the recovery. What this study shows is there are substantial financial implications, and specifically the earnings decreased from 8% to 31% in these individuals that had a heart attack or cardiac arrest or a stroke.

And these were individuals, by the way, that were of working age. This decrease in income occurred within the first year and persisted over 3 years, so that gap widened. The people that suffered the most were those that had the lowest earnings, those that were least able to afford it. Now this has implications not only for their living conditions, but also for their continued health, because at this particular stage, once you had an event, you’re likely to have additional medical problems, and you need to have the financial wherewithal to be able to address those. This has profound societal and personal effects.

Elizabeth: I would remind you, of course, that we know that there are really what are called “toxic effects” of economic burdens on people with cancer, and that these result in increased depression and decreased quality of life. I think that this is the first time, at least, I’ve seen this with regard to cardiovascular events, this kind of analysis. It’s definitely something that concerns me. The other thing I would notice that this is a study that took place in Canada, where people have guaranteed health insurance, and they also have a lot of social nets that help to keep them societally engaged in the event that these things happen, but we don’t have those here domestically, so I’m wondering what such a study might show for us.

Rick: Elizabeth, that’s a good point. The decrease in earnings here were from $4,000 up to about $13,000 and that’s in Canada. How does that translate to things in the U.S.? Unfortunately, this study doesn’t address that, but it suggests that the effects could be even more profound here.

Elizabeth: That’s what I think. I think we’d like to see such a study here. Since we’re talking about the heart, why don’t we turn to the Journal of the American Medical Association? Last week we talked about incentivizing people. This is incentivizing people to take their heart medicines.

Rick: Once an individual has had a heart attack, they’re often prescribed anti-platelet therapy — and oftentimes, two medications or what’s called “dual anti-platelet therapy” or DAPT. What we’ve noticed is, although these medications are recommended to be taken for a year, somewhere between 25% and 35% of patients don’t actually complete that year. And the cost of the medications is thought to be one of the reasons for that, because the copay associated with this dual anti-platelet therapy can be anywhere from $35 per month to as much as $400 per month, depending upon which agent is taken.

These authors conducted a study in over 300 hospitals, of over 11,000 patients that had had a heart attack. In about half those hospitals and half the patients, they provided them a medication copay voucher. That voucher was worth about $137 per month. The other half of individuals, they did not give them the voucher and they followed them for a year and asked how likely were they to complete the year of medication therapy? Secondly, did it improve their outcome?

What they discovered was that the patients who received the medication copay, they were more likely to take their medication. About 88% did so. And those that didn’t, however, it was about 84%, so there was a marginal benefit. However, over the course of the year, that didn’t translate into a decreased number of cardiac events. What this tells me is that, although decreasing medication copay can improve medication compliance somewhat, from 84% to 88%, in this patient population, there was still about 1 in 9 or 1 in 10 patients that still didn’t take their medications.

Elizabeth: And so I’d like you to step into that space and just speculate for me on what you think are the barriers to people taking their medicines even when they get supplemented monetarily.

Rick: That is a terrific question, and I’m glad that study was done because we, in the health care profession, like to blame a lot of it on the cost and think, “Gosh, if we can reduce the cost or help pay for the patients, we’ll increase compliance.” This study showed that it wasn’t the case.

And by the way, this compliance is much better than what’s reported in observational studies. We need to examine it. Are there cultural issues? Are there societal issues? Is it the fact that it wasn’t explained well to patients? Interestingly enough, of these patients that received medication vouchers, three-fourths of the patients used them. That means a fourth of patients didn’t even use it. They were given free money and they didn’t even apply it to their medications. There’s still a lot we need to figure out.

Elizabeth: Let’s turn from here to the New England Journal of Medicine. I served this up as, “Gosh, if you have to have your esophagus resected, which is the best way to do that?” Hopefully, most of us won’t ever have to address this issue, although the reason people have to have it, of course, is for cancer of the esophagus, a condition that’s increasing in incidence worldwide and especially domestically.

So in this study that was done in France, they took a rather small number of patients, actually, 103 patients who underwent what was called a “hybrid procedure” and 104 to what was called an “open procedure.” The open procedure, transthoracic open esophagectomy versus this minimally invasive esophagectomy. They took a look at lots of outcomes here. An important outcome, major intraoperative or postoperative complications, as well as was there an impact on survival?

What they found was that the hybrid operation resulted in significantly lower incidence of both intraoperative and postoperative major complications, especially the pulmonary complications, and did not compromise overall end disease-free survival in 3 years of follow up.

Rick: The overall survival with esophageal cancer is about 5% to 10%, unless it can be resected, in which case the survival goes up to about 40%. In this group of individuals that had localized esophageal cancer, no evidence of metastasis, and in the middle or lower third, historically, people would have a big operation, a big incision both in the chest and a big incision over the abdomen with a high complication rate.

So what these investigators attempted to do was to say, “Can we minimize the complication rate without sacrificing the benefit of the surgery?” And in fact, by doing minimally invasive surgery, lowered the complication rate by 70%. That’s pretty remarkable. Now as you said, it was a small study, but that small number was meant to address the issue of complications. It wasn’t powered to directly address survival, but it showed that, in fact, it didn’t go down. In fact, it was a little bit better in this study, but not statistically so. So the next study should take this and expand it to a larger patient population.

Elizabeth: I have to note that last week or maybe 2 weeks ago we talked about a minimally invasive approach to ovarian cancer resection, and we found that, in fact, that was not good. It resulted in compromised overall survival and disease-free survival. I think it’s really interesting that this site specificity is demonstrated in all of these studies. I’m glad to see them.

Rick: And I’m glad you picked this particular study.

Elizabeth: So let’s end, then, with the last one, which I’m really quite interested to hear your thoughts about. This is an assessment in the Journal of the American Medical Association of medical marketing over the last, hmm, decade plus.

Rick: Companies have really increased promotional activities to try to sell and increase their market share of their products and services and to kind of shape public opinion and also physician or clinician beliefs as well. So what these investigators did was they looked at a wide array of data. They analyzed consumer advertising, professional marketing, the FTC regulations, state attorney general, U.S. Department of Justice, peer-reviewed medical literature, business journals. A huge amount of literature to ask, “How has medical marketing changed over the last 20 years?”

You may or may not be surprised to know that this medical marketing isn’t only directed towards physicians, but it’s directed towards consumers as well. So over the last 19 years, direct consumer marketing has increased from $2.1 billion to $9.6 billion. And a lot of that, by the way, for prescription medications that are high cost, such as cancer immunotherapies and other high-cost biologics.

There’s been increasing advertisement of just diseases. In 1997, about 40 diseases — in 2016, 400 diseases. The amount spent on that has been from $177 million to $430 million, and the amount spent promoting drugs to physicians has increased from $15.6 billion to $20.3 billion over the last 19 years. So what this tells us is that this is big business and pharmacy is spending big money to try to influence both consumers and physicians.

Elizabeth: And I would note that they have just, most of the major pharmaceutical companies, announced that there are going to be price increases that are effective January 2019, and my respectful suggestion is, if they reduced the amount of money they were spending on all of this advertising, I bet they could not have to increase their prices.

Rick: And I want to speak directly to health care providers. This is a trust issue with our patients. They depend upon us to provide them the best medications that are evidence-based to show they either improve quality of life or survival at the lowest cost possible. You’ll never find a pharmaceutical company advertising a generic medication, even though there may be good evidence that it improves quality of life or survival. My plea to the health care providers is not to let pharmacy unduly influence your prescribing practices.

Elizabeth: On that note, that is a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.