The last word: Insurer-mandated de-simplification of HIV regimens and negative impacts
Facebook Twitter LinkedIn Email
Every HIV clinician in medicine has gotten the “Dear John” letter from insurance companies — the one that says “I know your patient has a great relationship with their HIV regimen, but we aren’t going to cover that nice, single-tablet regimen anymore. Instead, we are replacing the STR with the individual components, as this is more cost effective.” And while we can all cite the literature about improved compliance and outcomes with STRs, the ability to counter the claim of cost containment has remained elusive.
A Dutch study published in AIDS looked at 128 patients who were taking an STR of rilpivirine/tenofovir disoproxil fumarate/emtricitabine (Complera). An insurer mandated a change to rilpivirine + generic TDF/FTC as a two-tablet regimen. Almost half of the patients (n = 59, 46%) initially switched, but within 18 months, only 17 remained on it, for an acceptance rate of 13%. Of the remaining 111 patients, 29 (26%) returned to RPV/TDF/FTC (which was possible when it was deemed “medically necessary” by the prescriber), 51 (46%) switched to the similar STR RPV/TAF/FTC (Odefsey, which cannot be de-simplified as there is no generic TAF/FTC), and 31 (28%) switched to another STR.
The cost analysis showed that rather than incur a savings of €38,000 per month, real-world costs increased €3,000 per month. The authors noted that one possible reason for the very low acceptance rate, compared with the approximately 50% rate in two other studies (here and here), was that in the latter studies, physicians had open conversations with their patients about voluntarily switching to contain costs, relying on patient altruism while respecting the patient’s right to continue their regimen. In the current study, the switch was mandatory and often done at the pharmacy level, with patients getting a two-tablet regimen rather than an STR at their next refill.
Financial stewardship is an important part of medicine but so too is respect for the patient and fidelity to the physician-patient relationship. Insurers should bring both patients and HIV providers to the table before creating de-simplification policies, as saving money is not a guaranteed outcome from such mandated changes.
