New Study Reveals Little Consistency in Evidence Cited by Commercial Health Plans for Specialty Drug Coverage

Health Affairs, November 2019 cover

When the health care community talks about evidence-based medicine, it’s usually in the context of efforts to ensure clinicians are delivering treatments to patients that align with the best available evidence. But given the influence that health coverage can have on a patient’s access to a treatment, are health plans aligning coverage decisions to evidence?

To understand how health plans use evidence to inform coverage decisions, researchers from the National Pharmaceutical Council (NPC) and the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center evaluated 1,562 coverage policies issued by the 17 largest commercial health plans in the U.S., related to 203 specialty drugs indicated for the treatment of 167 diseases. The study, published in the November 2019 issue of Health Affairs, revealed significant variation in the consistency, volume and type of evidence being cited in coverage decisions for specialty medicines. Among their findings:

  • Only 15 percent of the health plan coverage policies cited the same study for any given drug and disease pair (e.g., policies for adalimumab to treat Crohn’s disease).
  • The volume of evidence used to inform coverage decisions varied greatly, from an average of 4 studies cited in coverage decisions by one health plan to an average of 64 studies cited by another health plan.
  • Even the breadth and types of clinical and economic evidence used to inform the coverage decisions varied, with few plans using a full range of evidence including real-world evidence, evidence synthesis and economic studies.

The study provides important insight into the findings from previous research published in 2018 by the NPC/Tufts team in Health Affairs. In that study, they found insurance coverage and reimbursement for specialty medications varied substantially, with only 15.9 percent of drug coverage policies consistent across the largest U.S. commercial health plans. For patients switching between insurers or employers, differences in coverage decisions may result in care disruption. Further, this requires physicians to tailor care around insurance coverage, which may or may not be the best treatment for the patient.

“Once we observed the inconsistency of coverage policies for specialty medicines, we wanted to explore what might be driving those variations,” said NPC Vice President for Comparative Effectiveness Research Jennifer Graff, PharmD. “While we expected some variation in the evidence that plans report reviewing, the extent of variation in the volume, composition, and consistency of the cited evidence is notable and may be a key factor behind the inconsistent coverage that patients encounter.”

The study highlights gaps in formulary development practices and provides important considerations as stakeholders assess potential updates to formulary practices that could better ensure patients have access to medications when the underlying clinical and economic evidence supports coverage.

“Patients should have access to evidence-based treatments. This study shows that, if we want to deliver evidence-based care to patients, we can’t just consider what’s happening in the clinical setting. We need to widen our lens and consider the decisions being made by payers, to ensure payment and coverage decisions are based on a complete examination — and more consistent use — of the evidence,” said Dr. Graff.

Read the study in Health Affairs here.