Paying for Patient Care

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Paying for Patient Care Infographic

Understanding the Costs and Benefit now and later

Patients switch insurance plans over their lifetime. The insurer that pays for treatments TODAY may not see the cost benefits of better health LATER.

This GAP between upfront costs and long-term savings may mean insurers are NOT INCENTIVIZED to cover transformative but expensive treatments for patients.

SHOW ME

Researchers compared the short-term vs. long-term costs of care, including:

  • Upfront costs of expensive, but transformative new TREATMENTS
  • Downstream cost savings of reduced HEALTH BURDEN and avoided care, like hospitalization, caregiving and more.

CONDITION Hepatitis C

  • HEALTH BURDEN Cirrhosis, liver cancer, liver transplants
  • TREATMENT One-time medication to CURE
  • WHICH INSURERS PAY FIRST? Commercial plan, Medicaid
  • HOW MUCH? $15k
  • WHICH INSURER SAVES LATER? Medicare
  • HOW MUCH DO THEY SAVE? $3k mainly by avoiding transplant

CONDITION Beta-Thalassemia (Rare Childhood Disease)

  • HEALTH BURDEN Chronic iron overload management, cardiovascular disease
  • TREATMENT One-time gene therapy to
  • CURE WHICH INSURER PAYS FIRST? Medicaid
  • HOW MUCH? $284k
  • WHICH INSURER SAVES LATER? Commercial plan
  • HOW MUCH DO THEY SAVE? $121k by avoiding transfusion

CONDITION Alzheimer’s Disease

  • HEALTH BURDEN Elder care, lost quality of life
  • TREATMENT Ongoing medication to SLOW disease
  • WHICH INSURER PAYS FIRST? Medicare
  • HOW MUCH? $96k
  • WHICH INSURER SAVES LATER? Medicaid
  • HOW MUCHDO THEY SAVE? $30k by avoiding long-term care costs

WHY CLOSE THESE GAPS?

New reimbursement approaches for transformative treatments can help ensure:

  • APPROPRIATE patient access
  • ECONOMIC INCENTIVES for future development
  • SUSTAINABLE ECONOMICS for insurers that pay for expensive but cost-effective therapies

HOW CAN GAPS BE CLOSED?

Potential novel solutions:

  • STRENGTHEN RISK-SHARING MECHANISMS - Refining and expanding existing approaches can help lower financial risk for insurers
  • DEVELOP ALTERNATIVE FINANCING MECHANISMS - Can include outcomes-based contracting that ties payments to treatment impact
  • UPDATE PRICING REGULATIONS - Regulations rooted in old approaches can be a barrier to new solutions NPC. National Pharmaceutical Council

Visit www.npcnow.org/paying-for-patient-care to learn more.

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