Analysis Conducted by University of
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
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
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/
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