The Role of Pharmaceuticals in Health Insurance Exchanges

One of the most pressing issues in the implementation of the Affordable Care Act (ACA) is whether the state health insurance exchanges, or marketplaces, will be effective in achieving their primary aim—ensuring patients have access to the health care they need.

As with most policy initiatives, the “devil is in the details.” Recently, NPC’s chief science officer, Robert Dubois, MD, PhD, led a discussion at the Health Insurance Exchange Summit on "Capturing the Value of Pharmaceuticals–A Look at Rx Coverage and Cost in the New Health Insurance Exchanges." He was joined by Dave Domann, MS, RPh, director health care quality, Johnson & Johnson Health Care Systems Inc.; Caroline F. Pearson, director, Avalere Health; and Mark Fendrick, MD, professor, Department of Internal Medicine & Department of Health Management and Policy, University of Michigan, and director, University of Michigan Center for Value-Based Insurance Design.

During the Summit, Dr. Dubois and the panel discussed the extent to which patients will have access to multiple treatment options under the exchanges and the importance of offering choices in care. The US Department of Health & Human Services (HHS) provisions require the new exchanges to offer a core set of items and services known as essential health benefits (EHB). Under these provisions, plans included in an exchange must cover at least one drug per class or the same number of drugs in each category and class as a state benchmark plan.

State exchanges that offer more limited treatment options could create challenges for providers and patients. Each patient is unique and treatment effects can vary substantially. One drug may work well in one group of patients, produce little benefit in another group or may cause significant side effects in a third set. For example, patients sometimes end up trying multiple kinds of antidepressants, because it’s difficult for doctors to predict which one will work best for them. In order to provide high quality care and achieve positive outcomes, doctors and patients must have appropriate access to various treatment options. Those who are responsible for administering state exchanges must carefully consider the unintended consequences and potential negative outcomes of limiting access so that they do not severely limit the number of options available in critical areas. 

It’s also important to ensure that patients are able to cover the costs of the treatments they need. Dr. Dubois noted that state exchanges can help lower barriers to care by wisely designing deductibles and co-pays so medications that prevent serious illnesses and manage chronic conditions are accessible for patients.

And as the Summit panelists noted, the state exchanges could be greatly beneficial to patients, as long as they’re designed in a way that captures the nuances of patient needs.

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