Building Better Benefits
Modernizing health insurance benefit design can improve patient access and affordability for innovative, high-value medicines.
Every year new medicines come to market that improve patient health by preventing, treating, and even curing diseases. These innovations bring tremendous value to both individuals and society broadly, but poorly designed health insurance can create barriers for patients in accessing these high-value therapies.
Most benefit design approaches focus on containing immediate costs for drugs and health services, rather than considering individual patient needs. But often long-term costs to the health system could be reduced if the patient receives appropriate care in a timely fashion and thus avoids hospitalization or other costly services in the future.
How can we build better health benefits?
By implementing evidence-based, patient-centered solutions that improve access while also controlling costs
This will require:
- Eliminating inappropriate hurdles to improve timely access to needed medicines
- Modernizing benefit design to incentivize access to high-value medicines
- Reducing patients’ out-of-pocket burden to support access to medicines and improve patient outcomes
Learn more about patient-centered benefit design.
Recognize Individual Patient Differences
Every person’s health needs are unique thanks to factors such as age, genetics, racial and ethnic background, chronic conditions, sex, gender, environment, and socioeconomic circumstances. Yet health care and insurance coverage are often designed for the “average” patient, assuming all people have the same needs or the same treatment responses.
NPC's The Myth of Average: Why Individual Patient Differences Matter explores how patients, providers, insurers and other decision-makers can better consider individual patient differences when navigating the complexities of health care and insurance.
Implement HDHP Good Practices
High-deductible health plans (HDHPs) can be problematic for people with low incomes or those with chronic conditions who need regular care or medications. They may end up paying thousands in health costs at the start of the year to meet their deductible, leading some to avoid needed care.
Read NPC's new report to learn how employers can design smarter HDHPs that optimize value and do a better job of meeting employee health needs.
Expand Access to Drugs and Services for Chronic Diseases
Recent NPC-sponsored research showed many employers have expanded pre-deductible coverage for drugs and services used to prevent exacerbations of common chronic conditions. This eliminates a financial barrier for patients by lowering their out-of-pocket costs and increases utilization of essential medicines, ultimately improving health outcomes.
Revise Step Therapy Protocols
Step therapy requires patients to try at least one — sometimes many — first-line (often less-expensive) medications before their health plan will cover an alternative drug. Unfortunately, these “steps” can require significant administrative resources from physicians and delay patient access to needed medications.
NPC research shows that while stakeholders including payer, provider, and patient groups don't always agree on when step therapy is appropriate, they do agree on criteria for how to develop, implement, communicate, safeguard and evaluate step therapy protocols so they account for patient needs and concerns, not just costs.
What can you do to improve health benefits?
Patients: Request better benefits. If you are on employer-sponsored insurance, talk to your employer about the barriers you face with your health plan and ask for solutions. Share this case study with your employer on engaging employees in the design of employer-sponsored health benefits.
Employers: Listen to your employees' needs and work with your insurance provider to select better benefits for them. Read this Action Brief outlining key steps that employers can take to enhance their health benefit design approach, and check out NPC's Employer Resource Guide for information and research on benefit design, health spending and more.
Health insurers: Work with patients to create better benefit designs that put patient needs at the center. NPC research shows that insurers aren’t asking patients for input when developing specialty drug coverage policies. Read about key principles for equitable benefit design and ways to modernize benefits to achieve more affordable, patient-centered care.
Policymakers: Learn why we need innovation in how we pay for health care and how problems with insurance benefit design are exacerbated by a broken drug rebate system.
Resources for Employers
Visit our dedicated page for employers and other benefit and formulary design decision-makers.