Is Cigna’s $500 offer to Patients for Switching Ethical?

MHE Publication, MHE September 2021, Volume 31, Issue 9

Copays and formulary tiers involve financial incentives to use certain drugs. But is Cigna’s offer of a $500 debit card in a different category?

Cigna members who switch from Cosentyx (secukinumab) or Remicade (infliximab) to an approved biosimilar will receive a $500 debit card, per a policy introduced in July by the insurance carrier. It’s marketed as an effort to lower prescription drug costs through the Shared Savings Program. Cigna is alerting treating physicians and the 7,000 affected patients individually.

Offering physicians $500 to prescribe biosimilars over name-brand drugs would clearly be unethical and likely illegal, says Leonard Fleck, Ph.D., professor at the Center for Bioethics and Social Justice at Michigan State University. But it is potentially ethically acceptable to offer the funds to patients under certain circumstances, he says. In the larger picture, financial incentives for using certain pharmaceuticals may contribute to wasteful administrative costs and does not benefit the patient, in Fleck’s view.

But Cigna estimates that in the short term, its clients will save at least 10% of Remicade’s cost for each patient who switches, with savings growth as biosimilars gain traction. “Biosimilars can save patients, their employers, health plans and the healthcare system billions of dollars over the long term,” Steve Miller, Cigna’s chief clinical officer, told Managed Healthcare Executive® in an interview in July.

Cosentyx is used to treat psoriasis, psoriatic arthritis, nonradiographic axial spondyloarthritis, and ankylosing spondylitis. Remicade is a treatment for arthritis, psoriasis, Crohn’s disease and ulcerative colitis. Patients on Remicade can switch to Avsola (infliximab-axxq) and Inflectra (infliximab-dyyb). Cosentyx doesn’t have an approved biosimilar so if patients switched, it might be to different biologic, such as Taltz (ixekizumab).

The offer could be seen as ethical if Cigna is respecting patient autonomy in deciding the best treatment. “We ought to respect patient choices in that regard,” says Fleck. However, “these drugs are called biosimilars for a reason. They are not perfect replications of the drugs they’re intended to replace.”

Biosimilars aren’t likely to negatively affect most patients, Fleck says, but it might be problematic for some. “You’re encouraging patients to make a medical decision about something they would not fully understand, and they would look at it as an economic transaction. There is a potential problem there.” The switching is arguably for Cigna’s benefit. “Then again, you can see from the perspective of a larger consumer group — everybody who has insurance through Cigna — that it could bring down overall healthcare costs for pharmaceuticals, and that’s not a bad objective,” says Fleck.

A person’s economic situation also has to be considered. For someone who is well off, a $500 debit card may not be worth switching medications, especially if the current one works well. But for someone who is economically disadvantaged, $500 is a lot of money. “That comes closer to being a coercive bargain,” says Fleck.

Patients on long-term treatments are usually told to consult with a physician before making any changes in their regimen. In this case, physicians would be consulted because a new prescription is needed. “But patients will put pressure on physicians to write the new script, which may or may not have medical consequences,” Fleck says.

Deborah Abrams Kaplan writes about medical and practice management topics.