Research has shown that there is inequity in access to health care and treatments, and how employers design their health benefits can either exacerbate or improve this problem for their employees.
The impact of this challenge was further quantified through new peer-reviewed research led by the National Pharmaceutical Council. In the study, published in the Journal of Managed Care & Specialty Pharmacy, researchers examined the impact of an employee’s income on their use of and access to specialty medicines that treat autoimmune conditions, including rheumatoid arthritis, multiple sclerosis and plaque psoriasis, among others. They found that lower-wage employees faced higher out-of-pocket costs, were less likely to use specialty medicines than higher-income workers and relied more regularly on emergency room care.
According to the research, there are several reasons for these findings. Affordability of specialty medicines is “a likely significant contributor,” and “low income has been identified as a distinct risk factor for suboptimal adherence” and greater rate of discontinuation with medicines. Employer-sponsored insurance coverage policies for medications vary and may be driven by agreements made between the employer and the pharmacy benefit manager (PBM). In addition, many of these plans have more than one specialty medication tier and are subject to coinsurance percentage cost-sharing instead of flat-dollar copayments. This typically results in greater out-of-pocket expenses for employees.
Understanding these challenges can guide the development of health benefit designs that benefit the people who need them most.
Examples of potential policy solutions to ensure more equitable benefit design include:
- Enabling employers to cover more medicines pre-deductible. Studies led by EBRI and supported by NPC found that employers offering Health Savings Account-eligible high-deductible health plans are interested in covering more medications and other health services used to manage chronic conditions prior to meeting the plan deductible. Providing coverage before patients meet their deductible eliminates a financial barrier for patients by lowering their out-of-pocket costs and increases utilization of essential medicines, medical devices, and diagnostic tests, ultimately improving health outcomes.
- Following best practices when designing high-deductible health plans. In addition to covering medicines pre-deductible, best practices that employers can use include providing Health Savings Account contributions, offering an investment option as part of the HSA, and offering an alternative plan design in addition to HDHPs.
- Eliminating copay accumulator adjustment programs. Under some health plans, direct payment assistance from a biopharmaceutical company to a patient counts toward a patient’s annual deductible and out-of-pocket maximum. Thus, the copay assistance accrues to the health plan rather than to the patient it was designed to assist.
- Reducing barriers such as step therapy. Step therapy – often referred to as “try and fail” – can lead to delays in care. Those delays in accessing a treatment that works might hold minor consequences for someone with seasonal allergies; for a patient with rheumatoid arthritis, for example, those consequences could be very serious. Those health impacts may translate into higher costs over time. Though health plans might see short-term drug cost savings using step therapy, those gains may be lost to long-term increases in hospitalizations or treating worsening conditions.
Beyond benefit design, the JMCP research findings highlight ongoing inequity issues, such as possible clinical bias in prescribing patterns for people with autoimmune conditions and systemic workplace disparities. More equitable benefit design may mitigate these challenges and be helpful in efforts to identify and address inequities in the delivery of health care services.