New White Paper Calls for Cooperation Among Drug Manufacturers and Health Insurers for Precision Patient Assistance Programs To Reduce Healthcare Costs

Business Wire

Analysis Conducted by University of Michigan Center for Value-Based Insurance Design

UPPER NYACK, N.Y.--(BUSINESS WIRE)-- Global Healthy Living Foundation (GHLF) today announces the publication of a new white paper titled, “Precision Patient Assistance Programs to Enhance Access to Clinically Indicated Therapies: Right Drug, Right Time, Right Cost-Share.” Written by the University of Michigan Center for Value-Based Insurance Design and funded by GHLF, the paper explains the push-pull between insurance companies (payers) trying to reduce medication costs by creating tiered formularies and pharmaceutical companies (manufacturers) trying to provide clinically evidenced, prescribed medications to patients at an affordable cost via patient assistance programs. Studies show that patient assistance programs result in better adherence and health outcomes, yet they also drive up healthcare costs as payers build “rebate” programs into their coverage cost-sharing calculations.

In lieu of payers and manufactures taking the unlikely action of radically altering their business practices, the white paper authors argue that in light of advances in precision, personalized medicine, patient assistance programs should be nuanced to meet the needs of individual patients based on both their clinical evidence and ability to afford prescribed treatments rather than a one-size-fits-all program.

“With the rise of patient-centered care and personalized medical technology, physicians and patients are communicating better to identify medications that match a patient’s short and long-term treatment goals, but the reality is that their intentions are often thwarted by payers restricting access in order to control rising healthcare costs. Often times, specialty medicines used by chronic disease patients, are the hardest hit,” said Seth Ginsberg, President and Co-Founder of Global Healthy Living Foundation. “While patient assistance programs have helped millions of patients remain stable on their medications and keep their chronic disease under control, we realize that copay cards can contribute to the rising costs of healthcare if used inappropriately. A possible solution is to tailor insurance and benefit programs based on a patient’s clinical history and verifiable financial need.”

Jump Starting the Status Quo with Value-Based Insurance Design

As explained in the white paper, while patient assistance programs help patients access prescribed medicines, payers and purchasers correctly deduce that they “undermine reasonable incentives for clinicians and patients to respect plan formularies and speed members toward deductibles and out-of-pocket maximum amounts they might not otherwise satisfy, thereby increasing expenditures.” They also push patients to branded, more expensive medications when a generic might lead to a clinically equivalent outcome.

Value-based insurance design (V-BID) tries to better align “out of pocket cost-sharing with the value of the underlying service.” In other words, V-BID understands that clinical value is dependent on the individual patient’s treatment needs and treatment goals. There is evidence demonstrating that when benefits are targeted to clinical goals, that it is possible to reduce cost-related non-adherence across different conditions. White paper authors suggest payers and manufacturers come together in a “truce” to enhance access to clinically indicated therapies and decrease the financial and logistical burden on patients/families and their health care team.

“Collaborative approaches that base assistance on the specific clinical needs of an individual are needed to serve patients’ best interests. A ‘precision’ patient assistance program can enhance patient-centered outcomes, reduce the harm associated with high cost-sharing, and maximize the health benefits from finite patient assistance resources,” said A. Mark Fendrick, M.D., Professor, Departments of Internal Medicine & Health, Management and Policy, Director, Center for Value-Based Insurance Design, University of Michigan.

Possible solutions outlined in the white paper include:

Payers would accept the use of support for consumer cost-sharing (co-pay assistance) when a specific medication is clinically indicated and has low potential for inappropriate use, forgoing utilization management (e.g., step therapy, prior authorization, formulary exclusions)
Manufacturers would ensure information on clinical appropriateness – including scenarios where a medication is not clinically appropriate – is well-communicated in patient assistance materials
If the government updated its guidance while maintaining the “firewall” between manufacturer donations and patient-facing grantmaking, it would allow patient assistance programs run by charities the option to prioritize access to assistance based on clinical need – not simply the timing of the application for assistance.

“Precision Patient Assistance Programs to Enhance Access to Clinically Indicated Therapies: Right Drug, Right Time, Right Cost-Share” can be access in full at http://vbidcenter.org/precision-patient-assistance-programs-to-enhance-access-to- clinically-indicated-therapies-right-drug-right-time-right-cost-share/

About University of Michigan Center for Value-Based Insurance Design

The University of Michigan Center for Value-Based Insurance Design (V-BID Center) is the leading advocate for development, implementation, and evaluation of clinically nuanced health benefit plans and payment models. Since 2005, the Center has been actively engaged in understanding the impact of innovative provider facing and consumer engagement initiatives, and collaborating with employers, consumer advocates, health plans, policy leaders, and academics to improve clinical outcomes and enhance economic efficiency of the U.S. health care system. For more information, visit www.vbidcenter.org and follow @UM_VBID.

About Global Healthy Living Foundation

The Global Healthy Living Foundation is a 501(c)(3) non-profit organization whose mission is to improve the quality of life for people living with chronic illnesses, such as arthritis, osteoporosis, migraine, diabetes, psoriasis, cardiovascular disease and chronic pain, by advocating for improved access to care at the community, state, and federal levels, and amplifying education and awareness efforts within its social media framework. GHLF is also a staunch advocate for vaccines. The Global Healthy Living Foundation is the parent organization of CreakyJoints, the go-to source for more than 100,000 arthritis patients and their families world-wide who are seeking education, support, advocacy and patient-centered research and ArthritisPower, the first ever patient-led, patient-centered research registry for arthritis, bone, and inflammatory skin conditions.