Suppose two customers who are both diagnosed with rheumatoid arthritis (RA) approach your pharmacy counter. The first line of treatment for RA works effectively for the first customer, but it doesn’t work well in managing the second customer’s symptoms. The second customer’s doctor recommends another treatment that is more effective for her, yet it is on a higher insurance tier and she will need to pay more coinsurance out of pocket. When is it ethical, or fair, for different patients with the same condition to be paying different amounts for their medications?
National Pharmaceutical Council (NPC) President Dan Leonard tackles this question in his latest commentary for Chain Drug Review. In it, he considers when variable cost-sharing is less acceptable for patients who require higher-tier formulary medications and highlights recent NPC research examining patient cost-sharing.
As part of this research, NPC brought together an expert roundtable of patient, payer, and employer representatives to determine when it would be more – or less – acceptable to require higher cost-sharing, as well as how the financial burden could be shared across patients, health plan members, and employers. They arrived at five guiding principles to understand when variable cost-sharing is less acceptable for patients who require higher-tier formulary medications, and identified five potential barriers – and their solutions – that must be considered to align out-of-pocket costs at the pharmacy counter with appropriate care.
“With the health care industry moving from volume- to value-based care, the fairness and incentive to follow appropriate care pathways while keeping patients’ costs low is taking center stage,” Mr. Leonard writes of these findings. “Cost-sharing is appropriate in the right situations, but when a treatment is proven and medically necessary, your customer’s bad luck is not one of them.”