How Patients End Up On Pricey Drugs That Are Marginal

Sometimes patients are placed onto drugs that cost 20 times more than the traditional mainstay drug for their condition, with both the provider and patient having little idea that the cost is not worth it.  How does this happen?  It takes an understanding of how expensive drugs come to be prescribed.

Sure there are some innovative new brand name drugs that really are superior to older generics.  But that is happening less frequently than it used to.  Big Pharma now scrambles to preserve high profits by finding new drugs, some of which are only marginally better than the older ones, but with some marketing and lack of head-to-head comparisons, the company can convince both providers and patients to try the new one.  And when there is lack of an objective endpoint (when dealing with symptoms like joint pain) then they seldom back up to use of the old drug.  There is even a placebo effect:  “This one must be better because it costs 20 times more than my old one.”

Let’s look at the process, using Humira as an example.  Humira is an injectable medication for Rheumatoid Arthritis (and some other conditions).  In 2015, it was one of the best-selling drugs in the world, topping $8 billion in sales.  If a patient had to pay full retail (such as in a high deductible plan), it could cost about $3500 per month.  If the health plan has a PBM (Pharmacy Benefit Manager to manage their medication costs) that PBM may negotiate a “rebate” of about $1500 that the pharmaceutical company would pay to the PBM (and health plan) in order to “buy their way” onto the formulary of the health plan (instead of being excluded in favor of a competitor).  Being a “specialty drug”, sometimes listed as a “Tier 4”, it could cost the patient about $400 per month if they have a 20% co-insurance rate.  At $400 per month is it really superior to the traditional gold standard: methotrexate, which is about $20 per month?  Research suggests:  not likely ( )

So how did it come to be prescribed?  Several possible reasons:  The patient didn’t tolerate methotrexate.  About 75% of patients are stay on methotrexate for greater than 5 years.  About 25% stop for one reason or another.  But studies show that half of that 25% can tolerate methotrexate if it is restarted, perhaps at a lower dose.  Sometimes this was not even tried.  Also, studies show methotrexate could be made more effective by addition of a second drug, leflunomide.  Often, this is not tried.  Sometimes the provider is influenced by Big Pharma marketing to believe that Humira is the best choice.  Sometimes the patient is persuaded by “direct-to-patient” advertising to see Humira as the greatest choice.  This can be out of desperation, even if it turns out it doesn’t work better than methotrexate.  But often, once started, Humira is continued because either the provider or patient (or both) sees it as the best possible treatment, with an absence of any objective test to show otherwise.

So, the reason that Humira is often used even though not often superior to methotrexate is multifold:  desperation, giving up too easy on methotrexate, failure to combine methotrexate with leflunomide, marketing influences on both providers and patients, and perhaps placebo effect of expecting better results with a pricey drug.  Is Humira sometimes better?  Yes.  But far too often, too many patients are paying excessively for a medication that costs 20 times as much without achieving more benefit.