Out-of-pocket costs of brand-name drugs remain high for people with chronic conditions

January 07, 2022

3 min read

Disclosures: Zhou reports receiving grants from the NIH Medical Student Research Training Fellowship. Dusetzina reports receiving grants from Arnold Ventures, the Commonwealth Fund, the Leukemia & Lymphoma Society and the Robert Wood Johnson Foundation, honoraria from West Health and the Institute for Clinical and Economic Review and serving as a member of the Medicare Payment Advisory Commission and a consultant for the National Academy for State Health Policy. Please see the study for all other authors’ relevant financial disclosures.

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Health care costs remained high for Medicare beneficiaries with common chronic conditions for which brand-name medications without generic alternatives were recommended, according to findings published in JAMA Internal Medicine.

“High out-of-pocket costs may reduce medication adherence and limit the benefit of guideline-recommended treatment while increasing the burden of treatment among patients with multiple chronic conditions,” Tianna Zhou, BS, a medical student at the Yale School of Medicine, and colleagues wrote.

Media inflation-adjusted out-of-pocket costs for Medicare beneficiaries with chronic conditions.
Zhou T, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.7457.

Zhou and colleagues conducted a retrospective cross-sectional study of 2009 and 2019 Medicare prescription drug plan (PDP) information to estimate the annual, inflation-adjusted out-of-pocket costs for hypothetical older patients with at least one of eight common chronic disease who adhered to guideline-recommended therapy. The chronic conditions included in the analysis were atrial fibrillation, COPD, heart failure with reduced ejection fraction (HFrEF), hypercholesterolemia, hypertension, osteoarthritis, osteoporosis and type 2 diabetes.

Overall, the researchers analyzed 3,599 Medicare PDPs from 2009, of which 1,998 were Medicare Advantage plans and 1,601 were stand-alone plans, as well as 3,618 Medicare PDPs from 2019, of which 2,719 were Medicare Advantage plans and 899 were stand-alone plans.

In total, 15 drug classes were recommended at least once in clinical practice guidelines for the chronic conditions, amounting to 47 medications in 2009 and 58 in 2019.

Costs for patients with a single condition

For patients with one condition enrolled in any PDP, median annual costs decreased from 2009 to 2019 for six of the eight conditions analyzed, including COPD (from $1,218 to $845), HFrEF (from $268 to $103 when treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, an evidence-based beta blocker and an aldosterone antagonist), hypercholesterolemia (from $128 to $36), hypertension (from $141 to $48), osteoarthritis (from $96 to $48) and osteoporosis (from $128 to $32).

However, the median cost for people with atrial fibrillation increased from $91 to $1,579, as did the cost for people with type 2 diabetes, from $172 to $992, and for those with HFrEF who were treated with an angiotensin receptor neprilysin inhibitor (sacubitril-valsartan), an evidence-based beta blocker and an aldosterone antagonist, from $268 to $1,018, according to Zhou and colleagues.

During the study period, the percent change in median out-of-pocket costs ranged from 75% for osteoporosis to 1,634% for atrial fibrillation.

Costs for patients with multiple conditions

For an older adult enrolled in any PDP with a cluster of five commonly comorbid conditions (COPD, hypertension, osteoarthritis, osteoporosis and type 2 diabetes), the researchers found that the median out-of-pocket cost in 2019 was $1,999, a 12% decrease from $2,284 in 2009. Yet, for an older adult enrolled in any PDP with all eight chronic conditions, the median cost in 2019 was $3,630, a 41% increase from $2,571 in 2009.

Stand-alone vs. Medicare Advantage PDPs

Stand-alone PDPs cost more than Medicare Advantage PDPs for the management of all single conditions in 2009, whereas stand-alone PDPs cost more than Medicare Advantage PDPs only for the management of atrial fibrillation in 2019, according to the researchers.

Overall, when adjusting for inflation, median annual costs for guideline-recommended medications for older adults with multiple chronic conditions generally decreased from 2009 to 2019.

“However, among those conditions for which brand-name drugs without generic versions became guideline recommended, out-of-pocket costs increased substantially between 2009 and 2019,” Zhou and colleagues wrote. “These findings suggest that not all older adults experience equal burdens associated with out-of-pocket medication costs.”

Provider advocacy

In a related commentary, Robert J. Besaw, MPH, a graduate student, and Stacie B. Dusetzina, PhD, an associate professor of health policy and an Ingram associate professor of cancer research, both at Vanderbilt University Medical Center, said that in recent years, Congress has received multiple proposals for limiting out-of-pocket costs. However, considering the prevalence of chronic conditions and the burden of health care costs, “it is worthwhile for physicians to consider whether there are lower cost treatment options available to their patients,” when feasible, they wrote.

“Ultimately, there is a need for both cost-conscious prescribing by physicians and redesign of Medicare benefits to better support beneficiaries’ access to needed drugs,” Besaw and Dusetzina wrote.


Besaw RJ, Dusetzina SB. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.7454.

Zhou T, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.7457.



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