How the Myth of Average Persists in Health Benefits

People are different and their health needs vary. Though differences among patients are common, these differences aren’t always considered in treatment and coverage decisions.

In the past decade, research has deepened our understanding of a simple fact: People are different and their health needs vary. Scientific leaps in precision medicine, an emerging body of research on differences in chronic disease outcomes, and a growing understanding of social determinants of health all point to this conclusion.

Though differences among patients are common, these differences aren’t always considered in treatment and coverage decisions.

In the newly-updated booklet, The Myth of Average: Why Individual Patient Differences Matter, the National Pharmaceutical Council (NPC) explores the barriers patients face when navigating the health care system and identifies opportunities for health care decision-makers to build better health care benefits and improve patient access to needed treatments.Myth of Average

“Health benefits are often designed based on the treatments that work for the ‘average’ patient,” said Kimberly Westrich, MA, vice president of health services research at NPC. “But if you differ from the ‘average,’ it can be an uphill battle to access the treatment that your health care provider thinks is best for you.” 

Individuals can respond in different ways to the same treatment due to factors such as age, genetics, chronic conditions, racial and ethnic background, sex, gender, environment, socioeconomic circumstances, and personal treatment preferences. In addition, an individual patient’s health needs can vary. Beyond the primary goal of successfully treating their condition, patients and their health care provider may want to minimize side effects, protect daily functioning and the ability to work, or ensure accessibility in how the treatment is administered. 

While biomedical research and the practice of medicine are increasingly recognizing and acting on patient differences, the myth of the ‘average’ patient still persists in health benefit design.

Kimberly Westrich, MA VP of Health Services Research, NPC

Yet health care decisions, especially those involving insurance coverage, are often made at the population level, rather than the individual patient level. The mechanisms used by health insurers to reduce spending and encourage careful use of health care services — like higher deductibles, higher copays or tiered access to medications — can create barriers to the most effective, appropriate care for some patients. In addition, Myth of Averagecoverage decisions may be informed by value assessment tools that don’t adequately consider the priorities or needs of individual patients.  

“While biomedical research and the practice of medicine are increasingly recognizing and acting on patient differences, the myth of the ‘average’ patient still persists in health benefit design,” Westrich said.

NPC’s Myth of Average booklet recommends that decision-makers designing health benefits: 

  • Align patient cost sharing with clinically appropriate care through variable or dynamic patient cost sharing and pre-deductible coverage for high-value medicines 
  • Implement more equitable benefit design 
  • Follow best practices for step therapy requirements 

For patients navigating our complex health care system, the booklet provides tips on how to evaluate health plan options, like assessing whether specific medications are covered under the plan or subject to prior authorization, and how to discuss treatment options with a health care provider, particularly if the patient doesn’t respond to the initial therapy.

Myth of Average

 

Download the booklet.

 

 

Myth of Average

 

View the infographic.