Transcript
Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, Dr. Marcus Shaker will share strategies for addressing access, cost, and equity in asthma care to help improve adherence. Dr. Shaker is a Professor of Pediatrics and Medicine at the Dartmouth Geisel School of Medicine in New Hampshire. Let’s hear from him now.
Dr. Shaker:
There was a really interesting study by Bickel from just a few years ago. It was published in the Journal of Pediatrics. And what this author did with his colleagues is they evaluated kids, I think they were under 18. And they evaluated the outcomes in their lung function when the third party payer or their insurance required them to switch their inhaler. And he actually found that this was associated with decrease in patients’ lung function. So when you talk about harm being done, this is harm being done. They're actually dropping lung function because a PBM has now switched to a different formulary product to have a greater economic incentive for the PBM. In fact, seven patients discontinued the inhaled corticosteroid completely. And what you'll probably be thinking is the real-world impact is probably much greater.
The other thing that's very interesting is when these medications are chosen by PBMs, you think, ‘oh, maybe it's the medication that we've been using for 20 years. Maybe it's the cheap medication.’ It's typically not. Interestingly, it's typically the more expensive medication that the PBM is getting a greater rebate for and they keep the rebate, and then the patients are switching to these newer drugs that are actually more expensive. So when we think about cost-effectiveness and how to make care more cost-effective, one way is to allow greater access.
And I think that the other downstream effect of that will be to improve equity. A lot of us are familiar both as patients and as clinicians with this whole idea of prior authorization and step therapy. There was another study that was done back in 2023 where they looked at prescription criteria across 28 countries, and there was significant variation. And what happens is that with these access and step therapies, it ends up delaying care because delaying access is going to increase the risk for asthma exacerbations. This becomes a poorly cost-effective equation. It ends up causing more harm to society and to patients. We know that step therapy increases care complexity, and it's not particularly patient-centered.
The other challenge with this step therapy is it really creates a situation that is not equitable because there was data that Andrea Apter published back in 2013, and she looked at rates of health literacy and adherence. And it's not going to surprise you to hear that adherence rates vary by health literacy. So if you have low health literacy, you're likely to have lower adherence. As that settles in, it becomes pretty apparent that if we're discriminating based on adherence, we're just discriminating.
So we really need to rethink the entire paradigm of step therapy and prior authorization and how we allow patients to access medications in this country. I think that you can talk about digital inhalers, you can talk about ways to connect with patients, and you can talk about meeting them where they are. But ultimately, what we need to do is begin to fix the system.
Announcer:
That was Dr. Marcus Shaker talking about how we can improve adherence among asthma patients. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
