For health care consumers, the rationale for why some medicines are covered by their insurer and others are not, or why some medicines require a higher copay than others, is often a mystery. From the patient perspective, the medicine or treatment prescribed by the doctor should be the one that works best, based on the patient’s biology and desired health outcomes. So why, if that medicine works best for them, are many patients finding it harder to access the medicines they need? What’s happening in the current health care environment, and what can we do?
Most health insurance coverage options are based on what works best for the average population; however, what works best for the average population may not work best for the individual patient. And while payers have to start somewhere for their coverage, that can leave out patients who are facing conditions such as epilepsy, cancer, HIV or autoimmune disorders, where doctors have to determine a very specific, personalized treatment regimen to manage those conditions.
Since health coverage options are more focused on populations, it is becoming more challenging for patients who need individualized care to access the treatments they need. According to a recent study published in the peer-reviewed American Journal of Managed Care, insurers are requiring that consumers and patients pay an even higher portion of their drug costs, not only for specialty medicines, but for “non-preferred” generic drugs as well. Typically, insurers placed all generics on the first tier of their formularies, with the lowest copay. Now some insurers are beginning to place certain generics—usually those that are more expensive—on a second tier with a higher copay. These are “non-preferred” generic drugs. For conditions like hypertension, diabetes, epilepsy, schizophrenia, migraine, osteoporosis, Parkinson’s disease and HIV, this includes drugs recommended as the first line of treatment, which is akin to making that condition “non-preferred.”
In recent months, insurers including Express Scripts and CVS Health announced plans to cut back further on the variety of medicines offered on their formularies for the 2015 coverage year. While both companies excluded “mostly traditional drugs to treat allergies, asthma, cardiovascular disease, dermatological conditions and pain, Express Scripts added hepatitis C treatment Incivek to its handful of excluded specialty products, while CVS Caremark dropped multiple sclerosis treatment Rebif.”
Narrow formularies and “non-preferred” generics aren’t the only barriers to access. Many employers are adopting consumer-directed health plans (CDHPs), such as health reimbursement accounts, as part of their benefit mix. As a result, many lower income, high health care need employees may be incurring the biggest brunt of high out-of-pocket costs associated with CDHPs. Unless the employer covers preventive medications or offers a prescription benefit card, these employees often have to meet a high deductible before their coverage begins. With limited budgets, many of these employees are cutting back or forgoing necessary treatments. If they are not thoughtfully designed, CDHPs can put such employees in a very tough predicament relative to affording the care and treatments they need.
According to a new Kaiser Family Foundation report, employers also are shifting toward defined contribution plans, in which a flat sum is given to an employee to pay for health care throughout the year. For employees with greater health needs, however, this change could result in a bigger cost burden.
These are the kinds of challenges that the National Pharmaceutical Council has been considering through recent research.
When it comes to CDHPs, NPC worked with the Benfield Group to survey large employers about how they develop their benefits plans and consider recommendations from pharmacy benefit managers (PBM) or employee benefit consultants (EBC). The research, outlined in a webinar and a soon-to-be published booklet, outlines “better practices” that some employers are starting to follow.
Another NPC study considered whether value-based insurance design (V-BID) could be utilized to provide better access to specialty medications, which are generally utilized to treat cancer, autoimmune and rare diseases. V-BID is built on the principle of lowering or removing financial barriers to essential, evidence-based, high-value clinical services to align patients’ out-of-pocket costs, such as copayments, with the value of services. Driven by the concept of clinical nuance, V-BID recognizes that medical services differ in the benefit they provide, and the clinical benefit derived from a specific service depends on the characteristics of the patient receiving it. The idea is to shift the focus from “how much” to “how well” we spend our health care dollars.
Through our research, NPC also has been highlighting the importance of recognizing individual treatment effects when developing and designing research, formularies and treatment plans. NPC’s portfolio of research, conferences, videos and other materials explain how patient differences should be taken into consideration by health care decision-makers. Today, research organizations like the Patient-Centered Outcomes Research Institute require researchers to include subpopulations in their study designs.
NPC’s research alone isn’t a magic bullet to solve these access challenges. But what it can do is foster conversations among health care stakeholders and help to remind us that we do have common ground: our vested interest in improving patients’ access to the treatments they need, their health outcomes, and their quality of life.