Support consumer access to specialty medications through value-based insurance design

The driving force behind consumer cost-sharing provisions for specialty medications is the acquisition cost and not clinical value. This appears to be true for almost all public and private health plans, says a new report from researchers at the University of Michigan Center for Value-Based Insurance Design (V-BID Center) and the National Pharmaceutical Council (NPC).

Specialty medications are those which usually require special handling and are often used to treat serious or even life-threatening conditions including cancer, rheumatoid arthritis, and multiple sclerosis. It is estimated that they account for a quarter of total pharmaceutical spending in the commercial market, and if current trends continue, this may rise to fully half of all pharmaceutical spending by 2018 for commercial healthcare plans.

The increased prescribing of these medications has been coupled with a recent trend by public and private payers to shift a larger portion of the medication costs to consumers. The report points out that one of the results of this policy has been an associated reduction in both essential and non-essential service use. In other words, this may be triggering cost-related non-adherence for some patients.

“It is imperative for decision-makers that cost-containment efforts don’t produce preventable reductions in quality of care,” said report author and V-BID Center Director, A. Mark Fendrick, MD. 

V-BID is one way of doing so. It is a model of insurance design that provides more generous coverage for services that offer known, evidence-based value, while offering less generous coverage for those where value is low. V-BID shifts the focus from “how much” to “how well” healthcare dollars are spent.

There are a variety of strategies that payers and purchaser can use, to apply V-BID to specialty medications. These include imposing no more than modest cost-sharing on high-value medications, reducing cost-sharing based on patient- or disease-specific qualifications, and selectively lowering cost-sharing for patients who fail to respond as desired to another medication based on current access restrictions used by insurance companies.