Cutting Copayments Improves Outcomes for Minority Patients After Heart Attack

When nonwhite heart attack patients were able to obtain cardiovascular medications without a copayment, their readmission rates for a major vascular event or coronary revascularization dropped significantly.

Initial results from the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial indicated that medication adherence is crucial to improving outcomes after heart attack. Now a secondary analysis of the results suggests that eliminating copayments for preventive medications can improve adherence and outcomes among nonwhite patients.

The MI FREEE trial evaluated the impact of eliminating copayments for secondary and preventive medications for patients who had been discharged from the hospital after a myocardial infarction. The study randomly assigned heart attack patients to receive full prescription coverage or usual prescription coverage for statins, beta-blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. The results indicate that eliminating copayments improved adherence and outcomes.

However, substantial racial and ethnic disparities in cardiovascular care have been documented, and a higher percentage of patients belonging to ethnic minorities report medication nonadherence due to cost. To assess whether a value-based insurance design, in which copayments are cut for evidence-based medications, could help reduce these disparities, the current study, published in the May 2014 issue of Health Affairs, involved a second analysis of data from the MI FREEE trial focusing on racial and ethnic differences.

Researchers from CVS Caremark, Aetna, and Brigham and Women’s Hospital analyzed a cohort of 2387 patients from the MI FREEE trial who self-reported their race or ethnicity. Although patients identified themselves as part of 1 of 6 racial or ethnic groups, the analysis categorized patients as white or nonwhite in order to maintain statistical power.

During the follow-up period, nonwhite patients in the usual prescription coverage group were less adherent to medications included in the study, were more likely to have poor clinical outcomes, and had higher rates of total health care spending than did white patients in the same coverage group. Full prescription coverage significantly improved medication adherence among all patients, but eliminating copays had a greater clinical effect in nonwhite patients. Readmission rates for a major vascular event or coronary revascularization were significantly reduced among nonwhite patients who received full prescription coverage but did not significantly change among white patients. In addition, eliminating copayments reduced health care spending by 70% among nonwhite patients, while spending did not significantly change among white patients.

The study authors note that the different effects observed across the 2 groups were most likely a result of nonwhite patients’ significantly lower adherence rates and higher risk of cardiovascular events at baseline compared with white patients. As more patients gain coverage under the Affordable Care Act, the authors suggest that eliminating copayments for effective cardiovascular medications may be one way to improve health outcomes and decrease spending among these patients.

“Our results demonstrate that a simple, low-risk benefit design change can improve clinical outcomes and reduce costs in nonwhite populations with cardiovascular disease while reducing disparities in care,” the authors conclude.