How properly did payers present “truthful” entry insurance policies? Primarily based on an latest ICER report titled “Evaluation of Limitations to Truthful Entry“, the headline figures appear fairly good:
General charges of concordance with ICER’s standards had been 70% for value sharing of fairly-priced medication, 96% for medical eligibility standards, 98% for step remedy, and 100% for supplier restrictions
At first look, this looks like very reasonable entry. Nonetheless, digging a bit deeper, reveals that sufferers do nonetheless face important hurdles.
The desk beneath reveals that whereas 70% of medication obtained truthful entry, that is based mostly on the 84 medication that had been really lined by insurance coverage. Of the 342 medication evaluated, nevertheless, most medication (75%, 258 out of 342) weren’t lined in any respect. De facto, this imply that value sharing was 100%! If we embody each lined and non-covered medication within the evaluation, then value sharing can be thought of truthful based mostly on ICER’s standards solely 17.4% (n=59 out of 352) of the time.
Payers had been extra more likely to observe ICER guidelines with respect to medical eligibility and limitations on step remedy, and supplier restrictions. Nonetheless, a few of these equity standards signify a comparatively low bar. As an illustration, ICER states that they’ve applied “a most variety of three steps allowed for a step remedy coverage to stay concordant with truthful entry standards”. Requiring sufferers to step by 2 not to mention 3 therapies, nevertheless, is extremely problematic for a lot of illnesses.
Briefly, do US business payers present truthful entry? The reply to this query doubtless will depend on the attention of the beholder.
