Coverage Decisions May Drive Potential Health Care System Inefficiency

A Comparison of Coverage Restrictions for Biopharmaceuticals and Medical Procedures

New research from Tufts Medical Center and the National Pharmaceutical Council indicates that patient access to therapies depends on factors other than cost and clinical benefit.

The study authors sought to understand whether payers systematically restrict some types of interventions more than others, independent of their value. Asking whether medications face higher thresholds for demonstrating value, they investigated the extent to which payer coverage decisions are associated with intervention type.

To arrive at answers, the researchers developed a dataset of top interventions and coverage decisions for ten top payers. Using logistic regression, they modeled the relationship between coverage, type of intervention, and cost effectiveness, either favorable or unfavorable.

The results of the analysis showed that 26.3 percent of medication coverage decisions and 38.4 percent of procedure coverage decisions were “more restrictive”: imposing more clinical restrictions or step restrictions relative to Food and Drug Administration label or clinical guidelines; or coverage that places a medication on an unfavorable tier. At a high level, the research demonstrates that payers restrict non-medication therapies more.

The researchers conclude that use of different criteria and measures to influence access to different types of therapies, or access to similar therapies covered under medical and pharmacy benefit policies, may introduce inconsistencies and inefficient care.

Read the full study in Value in Health