Cornerstones of ‘fair’ drug coverage: appropriate cost sharing and utilization management policies for pharmaceuticals

Abstract

At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy and required switching. In each of these domains we present ‘ethical goals for access’ followed by a series of ‘fair design criteria’ that can be used by stakeholders to drive more transparent and accountable drug coverage.

The Physician and Administrator-Reported Cost of Drug Utilization Management to Physician Practices: A Cross-Sectional Survey

“…As such, there is a clear need to define principles with which drug utilization management criteria are determined and evaluated. For instance, the AMA has released prior authorization and utilization management reform principles [ 38 ] and the National Pharmaceutical Council has published stakeholder views on step therapy criteria [ 39 – 41 ]. Similarly, the Institute for Clinical and Economic Review has released criteria for fair coverage of prescription drugs and used these criteria to evaluate how payer policies align with their fair access criteria [ 42 ].…”

Physician perceptions of drug utilization management: Results of a national survey

“…https://doi.org/10.1371/journal.pone.0274772.t001 This suggests that there is a need for the industry to define and implement principles for drug utilization management policies with the aim to ensure that these policies align more closely with clinical evidence. To this end, several stakeholder-driven groups-the Institute for Clinical and Economic Review (ICER), American Medical Association (AMA), Academy of Managed Care Pharmacy (AMCP) and National Pharmaceutical Council (NPC)-have recently proposed criteria with which to define value-based patient access [20][21][22][23]. While this is a good first step in moving the conversation in the right direction, these efforts and the practical implementation of such criteria remain in its infancy.…”

Use of prescriber requirements among US commercial health plans

“…Prescriber requirements can be an effective tool when specialized training is required to evaluate and diagnose a patient and may even help reduce the need for other UM criteria, since the health plan could rely on the specialist physician to identify patients who would benefit from the treatment. 11 In its recent report, "Cornerstones of 'Fair' Drug Coverage," the Institute for Clinical and Economic Review notes that there is a risk that prescriber requirements lead to unnecessary treatment delays, particularly for patients located in areas underserved by specialty physicians, and negatively impact patient health outcomes. 11 The report further notes that patients tend to face higher cost sharing when attending appointments with specialist physicians, which could prove to be a substantial financial burden if they require multiple visits.…”

“…11 In its recent report, "Cornerstones of 'Fair' Drug Coverage," the Institute for Clinical and Economic Review notes that there is a risk that prescriber requirements lead to unnecessary treatment delays, particularly for patients located in areas underserved by specialty physicians, and negatively impact patient health outcomes. 11 The report further notes that patients tend to face higher cost sharing when attending appointments with specialist physicians, which could prove to be a substantial financial burden if they require multiple visits.…”