The lesson of Liptruzet
DRUG BUST by Alan Cassels
• The people’s briefing note on prescription drugs
If you receive private benefits through your employment or pension plan, you probably consider yourself pretty lucky and so you should. After all, those benefits are there to help you with the cost of eyeglasses, physiotherapy, dental care and other forms of medicine not covered by provincial health agencies. Of course, the biggest portion of those benefits dollars goes to cover the mainstay of medicine: prescription drugs.
Over the years, I have taken a very close look at what Canadian employees are getting out of their benefit packages and – at least on the prescription drug front – I have only one overarching comment for them: stop getting swindled!
How is that happening, you ask? First of all, the union reps that take on the tough job of negotiating drug benefits for their members are often outgunned and outnumbered at the bargaining table. The employer, the insurer and the pharmaceutical industry seem to work in tandem and their interests are often aligned against those of the employee.
About 60-70% percent of an employee’s private benefits plan – administered by groups like Manulife, Great West Life, or here on the west coast, Pacific Blue Cross – is spent on drugs. You would think something so central to an employee’s compensation package would be intensely studied so both sides would be well aware of the workings of the drug plan. Sadly, this doesn’t seem to be the case.
Private benefits are important. Employers know they are crucial to keeping employees happy and productive. The union members believe they are a key entitlement, as important as regular health services. When bargaining, both unions and employers work hard to hammer out the best deal they can for their own side. The outcomes of those deals vary a lot and on drug coverage they almost always seem to tilt in favour of the interests of the insurance and pharmaceutical industry, against the employees’ best interests.
Why is this? One reason is that the unions are often distressingly bargaining blindfolded. Their reps are often not allowed access to key data on the drug plan spending patterns of their members. Without those data, they cannot develop proposals or agree to concessions in an informed way. Insurers might have incentives to keep drug spending high and collect a percentage of the total amount spent on drugs. Increased use of higher priced drugs could mean more profits for the insurers. Since drug spending data remain almost entirely in the hands of the employer, the deck is automatically stacked against the union.
Why should this matter? When my colleagues and I have sat down and looked closely at the products being paid for by an employee’s drug plan, we find some serious examples of waste and inefficiency: drugs being paid for that had generic alternatives; poorly tested, newer drugs known to have serious safety concerns being covered without restrictions; newer treatments being prescribed in place of safe, inexpensive alternatives. I have spoken to union bargainers on this point and they agree with me: it is impossible to bargain for better drug benefits when the one side (the union) doesn’t have access to basic facts – including cost and utilization figures – as well as basic knowledge of the comparative safety and effectiveness of the drugs being covered.
A recently approved drug named Liptruzet makes an excellent case-in-point for how badly the unions typically fare when it comes to getting the most from their benefits. Liptruzet is a combination of two different cholesterol-altering drugs: ezetimibe and atorvastatin. As I’ve pointed out in previous columns, the highest quality, systematic evidence available shows that most people who have high cholesterol won’t benefit from swallowing a daily statin such as Lipitor (atorvastatin), Crestor (rosuvastatin) or Zocor (simvastatin). Though some with a previous history of heart disease might see some small benefit. Statins have a range of adverse effects – mostly cognitive difficulties and muscle weakening – that make them intolerable for many users. And they are extremely costly to drug plans and individuals.
Ezetimibe – sold under the trade name Ezetrol or Zetia – works by preventing the absorption of cholesterol in the intestines and it is also currently combined with simvastatin in a drug sold as Vytorin. In terms of the clinical research, there is no evidence that ezetimibe (or Vytorin) has any real benefit beyond lowering LDL cholesterol, which is to say, ezetimibe doesn’t do what a physician expects – prevent heart attacks or deaths in patients – plus there is some evidence ezetimibe increases the risk of cancer and narrowing of the arteries.
Many private drug plans, which have been bargained for through the hard work of your union reps, currently cover ezetimibe, no-questions-asked, in stark contrast to many public drug plans that would refuse to cover a treatment with such clearly unproven benefit. In Canada, ezetimibe currently costs employees and employers tens of millions of dollars every year because private plans generally don’t base coverage on a drug’s overall effectiveness and value-for-money considerations, which drive public plans.
This ‘new’ combo pill, a mix of atorvastatin (Lipitor) and ezetimibe (Ezetrol), sounds promising and free samples by the truckload will soon be delivered to our doctors so they can regift them to their patients. The big question is does Liptruzet work? The short answer is “No.” The drug company Merck acknowledged this in a press release: “No incremental benefit of Liptruzet on cardiovascular morbidity and mortality over and above that demonstrated for atorvastatin has been established.” Let me translate: there is no proof the drug combination works any better than Lipitor on its own, which is now cheap and generically available as atorvastatin in Canada.
Seems I’m not the only curmudgeon stupefied that the FDA has approved the drug for sale. Dr. Steven Nissen, head of cardiovascular medicine at the Cleveland Clinic, called this new product a “tricky move, but one which doesn’t make folks any healthier.”
So why should the unions care about this new drug? It’s because when the spanking, new Liptruzet arrives on the Canadian market – sold probably for $3 to $5 per pill (price yet to be established) – there is a good chance your private drug plan will automatically cover it, no questions asked. (Such as we saw with Vioxx when it first arrived in Canada.) This new combo drug, likely costing up to five times that of generic atorvastatin, will cost employer-sponsored drug plans millions more across Canada.
There is a very basic opportunity cost here for the unions: paying millions more for drugs that do nothing means less in your pay packet and fewer benefit dollars for other things you might value – maybe better dental care or a gym membership.
There are ways to improve this situation. When unions sit down to negotiate their compensation package, they need to be prepared to ask some hard questions and fully understand what exactly their drug benefit plans are paying for. They need to know if their drug plans are structured to maximize value, encouraging coverage of drug products that are effective, safe and cost efficient. They need assurance their money will not be wasted on every new, ineffective drug that comes along.
The money being wasted on unproven, newer drug treatments is not theoretical. It is your money and as a union member you have a right to ensure it is not being wasted. To do their best work for you, your union reps need to be armed with a good grasp of the plan’s data, analyzed in aggregate, anonymous form. They need to understand those data thoroughly so they can negotiate effectively with employers and demand value from the insurers. Reps have a right to those data and they need to be able to seek out advice on how to manage the growing costs associated with the arrival of new drugs. They need to ask, “What is in the best interests of our members and how can we ensure our plan is making drug coverage decisions in our interests?”
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Alan Cassels is the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease. Follow him on Twitter @AKECassels or www.alancassels.com