In order to achieve optimal patient outcomes and improve the effectiveness and efficiency of our health care system, payment and delivery models must recognize individual patient differences and ensure meaningful access to appropriate medicines.

Patients today may have greater access to health insurance, but many patients still lack meaningful access to medicines. The barriers to meaningful access include:

  • high-deductible health plans, which require patients to pay more costs out of their own pockets;
  • increasingly narrow lists of medications that insurers will pay for; and
  • complex approval processes, such as prior authorization review or step therapy (requiring a patient to try one medicine before another).

These three barriers, among others, also cause delays in patients starting a treatment regimen or switching to a more effective treatment if the first one is not working.

These approaches are based on efforts to contain drug costs rather than considering individual patient needs and potential cost offsets. For example, costs to the overall health system could be reduced if the patient is receiving appropriate care and avoiding hospitalization. Too often, cost containment is focused solely on reducing drug costs without recognizing other costs and factors related to patient care.

The National Pharmaceutical Council's research has taken a closer look at pharmaceutical access issues, examining topics such as:

  • the importance of access to a variety of treatment options because patient reactions to the same medications may differ;
  • ethical concerns where similar patients pay widely differing amounts based on whether their illness responds to lower cost therapies; and
  • how to address the rising financial burden on patients and the health care system.

In addition to these topics, the National Pharmaceutical Council has considered the impact of payment and delivery systems on patient access to care. As providers move from fee-for-service (being paid for each service or treatment) to performance-based reimbursement (being paid based on the value and quality of the group of services received), concerns arise that rather than patients receiving too much care, they will receive too little.

Factors that impact both physician payment and patient care include, among others: 

  • Inadequacy of the current breadth and depth of quality measures that physicians are required to meet;
  • Treatment, or care pathways, often require physicians to follow particular treatment steps for patients, yet there are no best practices, little is known about their impact on patient outcomes, and the elements of pathway development, implementation and evaluation should be clear to providers and patients; and
  • New financial incentives can change accountable care organizations' (ACO) use of key interventions. For example, ACOs can more optimally manage medications and achieve both desirable patient and fiscal outcomes.


Health Benefit Design

The National Pharmaceutical Council's research examines some of the pressing issues around how health benefits are structured, including value-based insurance design, consumer directed health plans and the impact of benefit restrictions, among other topics.

Provider Reimbursement

From accountable care organizations and integrated delivery networks to bundled payments and value-based insurance design, innovative payment and delivery models are gaining traction all over the country. The National Pharmaceutical Council's research takes a closer look at these new payment models and identifies the critical role biopharmaceuticals play in this changing health care environment.