Report: Access to specialty medicines should be determined by clinical value, not cost

WASHINGTON — As healthcare decision-makers grapple with how to ensure access to specialty medications, the University of Michigan Center for Value-Based Insurance Design and the National Pharmaceutical Council on Monday released a new report, "Supporting Consumer Access to Specialty Medications Through Value-Based Insurance Design," which explores how value-based insurance design could be utilized to address specialty medication access concerns.   

V-BID is built on the principle of lowering or removing financial barriers to essential, evidence-based, high-value clinical services to align patients' out-of-pocket costs, such as co-payments, with the value of services. Driven by the concept of clinical nuance, V-BID recognizes that medical services differ in the benefit they provide, and the clinical benefit derived from a specific service depends on the characteristics of the patient receiving it. According to report author and V-BID Center director, Mark Fendrick, V-BID seeks to shift the focus from "how much" to "how well" we spend our healthcare dollars. 

Acquisition cost, not clinical value, typically is the driving force behind consumer cost-sharing provisions for specialty medications in nearly all public and private health plans. "It is imperative for decision-makers that cost-containment efforts do not produce preventable reductions in quality of care," Fendrick said.

Payers and purchasers can use a variety of techniques to apply V-BID to specialty medications, including:

  • Imposing no more than modest cost-sharing on high-value medications;
  • Reducing cost-sharing based on patient- or disease-specific qualifications;
  • Selectively reducing cost-sharing for patients who fail to respond as desired to another medication based on current access restrictions used by insurance companies; or
  • Using cost-sharing to encourage patient selection of high-performing providers.

The authors point out that it will be critical to anticipate and address some of the foreseeable challenges associated with clinically nuanced benefit designs to make V-BID work effectively for specialty medications.  

As Americans are responsible for an increasing portion of the cost of medical care, cost-related non-adherence of potentially life-saving interventions is a real and growing problem, Fendrick noted. While a comprehensive V-BID program for specialty pharmaceuticals may not be immediately feasible, significant headway can be made by beginning with certain high-priority medications or clinical conditions, Fendrick added.

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