Novel Anticoagulation Options:Target-Specific Oral Agents an - Episode 7

Are Newer Oral Anticoagulants Cost-Effective?


The MD Magazine Peer Exchange “Novel Anticoagulation Options: Target-Specific Oral Agents and Their Antidotes” features leading physician specialists discussing key topics in anticoagulation therapy, including the clinical characteristics of current and emerging agents and criteria for use in specific patient populations.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

  • Scott Kaatz, DO, MSc, Chief Quality Officer at Hurley Medical Center in Flint, Michigan, and clinical associate professor at Michigan State University
  • Seth Bilazarian, MD, clinical and interventional cardiologist at Pentucket Medical and instructor of medicine at Harvard Medical School
  • Gerald Naccarelli, MD, Bernard Trabin Chair in Cardiology, professor of medicine and chief of the Division of Cardiology at Penn State University School of Medicine, and associate clinical director at Penn State Heart and Vascular Institute in Hershey, Pennsylvania
  • Christian T. Ruff, MD, associate physician in the cardiovascular medicine division at Brigham and Women’s Hospital, and assistant professor of medicine at Harvard Medical School in Boston

In this segment of the Peer Exchange, the panelists discuss direct and indirect costs associated with treatment with an oral anticoagulant vs. treatment with warfarin. They note that although it may be cheaper in terms of overall healthcare expenditures to prescribe one of the new oral anticoagulants, it won’t matter if they’re not covered by insurance or if the patient can’t afford the copay.

Peter Salgo, MD, starts things off by asking the panelists their views on how the differences in outcomes between treatment with warfarin and treatment with a new oral anticoagulant affect medical costs.

Seth Bilazarian, MD, said that nowadays all clinicians are thinking more about the costs of the medications they prescribe. He said “I’m asked to think about it not only as a steward of our healthcare system on the ground, but also as someone who’s part of an accountable care organization.”

He said it is also important when talking about healthcare costs to think about who is paying the cost. “Are we talking about the patient’s cost, the pharmacy benefit manager’s cost, or society’s cost? Some of the vagaries of our healthcare system make this a complicated question to answer,” Bilazarian said.

A clinician may make a convincing argument to the patient as to why she should be taking an oral anticoagulant, but it won’t matter at the end of the day if that patient can’t afford the copay for the drug. For many low-income (and even average-income) patients, that $40 copay is cost-prohibitive and may lead them to opt for warfarin instead, which “is essentially free because the pharmacy benefits managers have incented its use,” according to Bilazarian.

Then there are the other direct and indirect costs associated with warfarin use compared to treatment with an oral anticoagulant. Bilazarian noted the warfarin management service at his practice “involves two full-time nurses who aren’t compensated, so that’s a direct cost to our practice which is not reimbursed.”

The there are the costs associated with ischemic (bleeding) events: helicopter rides to the hospital for patients with an intracranial hemorrhage, phlebotomy costs, laboratory costs, rehab costs, etc.

“If we’re looking at overall societal costs, I think there have been several economic analyses that have shown that these novel agents are less expensive than the total cost for warfarin. But we can’t get patients to use them because of the copay,” Bilazarian said.

Scott Kaatz, DO, said he’s not sure they’re cheaper. In a recent systematic review of cost-effectiveness done in 4 countries, “if you look at just the US studies and use the traditional $50,000 per quality adjusted life year, almost always they meet that threshold, but none of them meet the threshold of being cost savings. They were cost-effective, very similar to what it costs to do mammography, or hypertension treatment, or dialysis, other things that we accept.”

Clinicians who prescribe an oral anticoagulant without having a conversation with the patient about cost are not doing as good a job as they think they are, said Christian T. Ruff, MD. “If the patient doesn’t fill the prescription, you haven’t done that patient a service because now they’re completely unprotected,” he said. Maybe they’ll go back to aspirin. The patient has to understand and be able to afford the cost of the newer oral anticoagulants, “or else they’re not really an option. Because the out-of-pocket costs of warfarin, for a lot of patients, may be all they can afford,” he said.