How effectively did payers present “honest” entry insurance policies? Primarily based on an current ICER report titled “Assessment of Barriers to Fair Access“, the headline figures appear fairly good:
General charges of concordance with ICER’s standards had been 70% for value sharing of fairly-priced medicine, 96% for scientific eligibility standards, 98% for step remedy, and 100% for supplier restrictions
At first look, this looks like very reasonable entry. Nevertheless, digging a bit deeper, exhibits that sufferers do nonetheless face important hurdles.
The desk beneath exhibits that whereas 70% of medication acquired honest entry, that is primarily based on the 84 medicine that had been truly lined by insurance coverage. Of the 342 medicine evaluated, nevertheless, most medicine (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 medicine within the evaluation, then value sharing can be thought-about honest primarily based on ICER’s standards solely 17.4% (n=59 out of 352) of the time.
Payers had been extra prone to observe ICER guidelines with respect to scientific eligibility and limitations on step remedy, and supplier restrictions. Nevertheless, a few of these equity standards characterize a comparatively low bar. As an illustration, ICER states that they’ve carried out “a most variety of three steps allowed for a step remedy coverage to stay concordant with honest entry standards”. Requiring sufferers to step by means of 2 not to mention 3 therapies, nevertheless, is extremely problematic for a lot of illnesses.
Briefly, do US industrial payers present honest entry? The reply to this query seemingly is determined by the attention of the beholder.
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