Does a One Size Fits All Cost-Sharing Approach Incentivize Appropriate Medication Use?
Patients contribute to health care costs through out-of-pocket expenses, like
copays and coinsurance. These cost-sharing mechanisms are intended to help payers
manage costs and encourage more efficient use of health care resources.
When is higher cost-sharingfor patients less acceptable?
Check out NPC’s 5 guiding principles
“Try and fail” is importantIf the initial lower-cost therapy is unsuccessful, patients should
have access to higher-cost therapy and lower out-of-pocket
costs. This is also known as “reward the good soldier.”
Benefits are certain and significant. If there is high confidence the health benefits of a treatment
are significant, then financial barriers should be lowered.
Costs must align with benefits. If the treatment costs are balanced with better effectiveness
and safety, then cost-sharing should be lower.
Don’t penalize for “bad luck”. If patients need higher-cost treatments based on their
biology or genetics, then cost-sharing should be reduced.
Lower, but do not eliminate,
out-of-pocket costs. Cost-sharing differences incentivize trying lower-cost treatments
first, but big jumps in costs for patients should be avoided.
Source: Graff JS, Shih C, Barker T, Dieguez G, Larson C, Sherman H, Dubois RW. Does a One-Size-Fits-All Cost-Sharing Approach
Incentivize Appropriate Medication Use? A Roundtable on the Fairness and Ethics Associated with Variable Cost Sharing. J Manag
Care Spec Pharm [Published online February 2017].