Dr. Ackerman discusses the “hidden long-term costs” of step therapy for OAB

In this interview, A. Lenore Ackerman, MD, PhD, discusses the "hidden long-term costs" of step therapy for overactive bladder (OAB), which she highlights in her paper, “Penny-wise but Pound-foolish: The hidden costs of step therapy for overactive bladder.” Ackerman is a urologist at the University of California, Los Angeles Medical Center.

Video Transcript:

There are 2 ways to go. One is if you're able to get the patient the right medication, and by right medication, I mean for that patient. Let's say that they're really not appropriate for an anticholinergic; you're trying to get them a β₃ agonist. Even just the process of getting that β₃ agonist is going to cost them time and energy and effort that can be quite frustrating and take a lot out of you. On top of that, there are typically delays in getting patients that care, because you have to wait for the appeal or the prior authorization or the insurance approval. And very frequently, even when you can get those medications covered under a prior authorization, the out-of-pocket costs to patients can be substantially higher. We actually did another study, recently, where we looked at what formularies say that patients would pay for some of these more recent β₃ agonists. What we found is that almost none of the insurance plans that we had surveyed offered it for a co-pay of less than $50 a month. When you consider that in comparison with oxybutynin, which often you can get for $5 a month—on GoodRX, you can get it for a couple dollars a month—there is a substantial cost to patients, even when you can get them the right therapy. That's sort of the best-case scenario, when you're getting a medication that's actually covered, you're getting it at this specific pharmacy that that insurance company contracts with.

Let’s say you don't know about all of these little things that can happen, and you go to get it at your neighborhood CVS, and they charge you $200. You pay it anyway because you don't know that there's another option, and you don't know that sometimes the pharmacy you get it at makes a difference or that you got a 90-day supply instead of a 30-day supply. So, all those little things can really add up as costs for patients. They want to be better, and they'll often do some pretty extreme things to get better. It's just really unfortunate that all of these things add up even when we can get them the medicines that we want.

Now, let's say we don't get them the medicines that they want. Well, there are 2 options there. One, they end up on a suboptimal therapy that I wasn't super happy about, something like one of these early, nonspecific anticholinergics, and now they've got all these [adverse events]. So now they're buying Metamucil and MiraLAX to try to manage their constipation, and eye drops, and they're having to drink water late into the night because their mouth is so dry, so their OAB is not really getting that much better. They're still in diapers, and they're still needing all of these other things to help manage all the [adverse events] of the medication, and that's if they stay on it. Because the odds are, at least from all of our studies, 80% to 90% of them are just going to stop taking it.

So, then they're just going to be in that second boat, which is not getting therapy at all. Then they're spending all this money on diapers and on underwear. They're starting to do all these other things that I think are much more concerning and it's the hidden costs of all of this, which is now they're limiting their life. They're not going out, they're not being social, they're not interacting with people, [and] they're afraid to be intimate. All of those social connections, which we know are hugely important to both just quality of life, but also longevity. I mean, these things directly influence how long you live and how happy you are while you're doing it. So, all of that is a very hidden cost of not being able to provide patients with medications that are sustainable for them.

This transcription has been edited for clarity.