Weighing Pharmacy Savings Against Downstream Medical Costs in CKD

In "Weighing Pharmacy Savings Against Downstream Medical Costs in CKD," the panel examines why total cost of care, not pharmacy spend alone, should guide generic switching decisions.

Dr. Haumschild walks through how his organization weighs short-term pharmacy savings against downstream medical costs. He does not want to save one hundred dollars on the pharmacy benefit at the wrong price. That savings makes little sense if it creates a ten-thousand-dollar impact on medical expense elsewhere. The numbers always need to be modeled, but that principle guides every decision. He points back to DAPA-CKD, which demonstrated substantial reductions in CKD progression for patients. It also reduced the composite of cardiovascular death or heart failure hospitalization meaningfully. EMPA-KIDNEY showed significant reductions in kidney disease progression and cardiovascular outcomes as well. Dr. Haumschild says those outcomes have to factor into any cost conversation directly. Dialysis, hospitalizations, and emergency department utilization are extremely resource intensive across the board. That resource burden falls on the budget, the member, and the healthcare team simultaneously. When evaluating a generic-driven formulary change, several inputs matter beyond the acquisition price alone. Net savings on the medication itself is only one piece of that picture. Member out-of-pocket cost, expected switch rate, and abandonment or adherence rate all matter too. Clinical equivalence for the relevant indication and downstream medical utilization round out the analysis. For new patients, he says aggressively leveraging a lower-cost generic usually makes clear sense. For patients already stable on therapy, the calculation looks different and requires more caution. He asks what threshold justifies switching a stable patient without creating disruption in their care. His conclusion is that the appropriate unit of analysis is not the pharmacy PMPM figure. It is the total cost of care and the total outcomes experienced by the member.

Our next episode, "Mortality vs Composite Data: Comparing SGLT2 Inhibitor Trials," turns to why two SGLT2 inhibitors with similar composite results can carry very different mortality evidence.