In this month’s newsletter, we’re diving into a hot topic in the healthcare industry: the utilization of newer, higher-cost medications. With drug prices climbing, it’s crucial to understand what drives their adoption and whether they truly offer value over older, less expensive alternatives.
But first, the Star Wars take. Darth Sidious (Emperor Palpatine) plays an incredibly important role throughout the primary canon events in Star Wars. As a later generation in Darth Bane’s line of Sith, Sidious is a strong believer in the rule of two. The rule of two, refers to the existence of only two Sith at any given time, a master and apprentice; although, every apprentice often teeters this line by having secret pupils of their own.
As a means to enhance the Sith lineage, the belief is that the Sith apprentice must eventually kill their master and, thus, become the master with their own apprentice. This ensured sacred and important knowledge would survive, as the Sith themselves continued to develop greater skills and ways to bend the force to their will.
We see Sidious “upgrading” apprentices throughout the canon films. Maul the first, followed by Tyranus (Dooku) and lastly Vader (our beloved Ani). Anakin was always his ideal apprentice since he learned of his existence.
The question now, did Sidious actually upgrade his apprentices? Is newer, better? A simple YouTube search will show countless videos comparing Jedi and Sith alike. While I would agree that Vader is an upgrade over his predecessors, the same is not necessarily true of Dooku over Maul. In fact, we see Maul best Dooku on a number of occasions in the “Son of Dathomir” run (a comic series derived from spliced episodes of the Clone Wars animated series).
Rarely is newer definitively better, be it Sith or new drug.
Key Factors Driving Utilization
The use of newer, costly medications can be attributed to three main domains:
Clinical Superiority: New medications often claim to be better than existing treatments, aiming for improved outcomes. A prime example which achieves this is Entresto, a drug for heart failure. The Paradigm study demonstrated its superior effectiveness compared to older ACE inhibitors like enalapril, showing reduced hospitalizations and cardiovascular deaths. Despite Entresto’s higher cost of $500-$600 per month versus a few dollars for enalapril, the improved patient outcomes justify its use.
Safety and Ease of Use: Medications that offer a better safety profile or simpler administration often gain favor. For instance, Aimovig for migraine prophylaxis shows fewer side effects compared to Topiramate via the HER-MES comparison study. Patients had a range of efficacy, indicating some may achieve the same ideal outcomes with Topiramate relative to Aimovig. However, even if both have similar efficacy in some patients, providers may opt out of its use before knowing how well it works, due to an increased side effects probability. The ease of a once-weekly injections, as seen with newer GLP-1 agonists like Mounjaro and Ozempic, is a significant factor in patient and provider preference. Older GLP-1s like Byetta and Victoza did not offer such convenience and attributes to why their utilization has dropped. Even semaglutide has an oral form in Rybelsus, for individuals not too fond of needles.
Industry Influence: The role of Pharmacy Benefit Managers (PBMs) and manufacturers cannot be overlooked. PBMs may encourage the use of higher-cost drugs due to rebates or other financial incentives through aggregators. Allowing easy access to higher cost drugs benefits their bottom line. Manufacturers also influence drug utilization through direct-to-consumer ads and by seeking new FDA indications for high revenue drugs like Humira and Enbrel, to extend patent life and market share. These drugs were first indicated for rheumatoid arthritis but have since expanded indications due to success with other inflammatory conditions.
The Balancing Act: Cost vs. Benefit
While newer medications can offer significant benefits, it’s essential to scrutinize whether these benefits outweigh their costs. For instance, Entresto provides superior outcomes and justifies its higher cost. On the other hand, less expensive drugs (such as our Topiramate/Aimovig comparison) might be as effective for some patients relative to newer products, with comparable side effects.
It’s vital to ensure that the decision to prescribe a newer, costly medication is backed by clear, undeniable clinical benefits. Safety profiles, side effects, and overall efficacy should always be considered in context. The goal is to balance cost-effectiveness with clinical advantage to ensure that patients receive the best care possible without unnecessary financial strain.
The Takeaway
In healthcare, “newer and more expensive” doesn’t always equate to “better.” A thorough evaluation of each medication’s benefits, costs, and potential side effects is crucial. Always aim for a solution that offers real clinical benefits and is aligned with patient needs and industry practices.
Thank you for indulging my fanaticism of both drug management and Star Wars. For more insights and updates, don’t forget to like, subscribe, and follow me on LinkedIn.
Best regards,
Dr. Ryan Garner