A Comparison of Coverage Restrictions for Biopharmaceuticals and Medical Procedures

Authors: Chambers J, Pope E, Bungay K, Cohen J, Ciarametaro M, Dubois RW, Neumann P
Publication: Value in Health, published online December 6, 2017
 

Research published in the December 2017 edition of Value in Health demonstrates that payer evaluation and coverage of pharmaceuticals and medical procedures may differ independent of their clinical benefit. Therapy access depends on factors other than cost and clinical benefit, suggesting potential health care system inefficiency.

Researchers from Tufts Medical Center and the National Pharmaceutical Council sought to understand whether payers systematically restrict some types of interventions more than others, independent of their value. They asked whether medications face higher thresholds for demonstrating value and investigated the extent to which payer coverage decisions are associated with intervention type.

The researchers examined a total of 392 medication coverage decisions and 185 procedure coverage decisions. The results of their analysis showed that 26.3% of medication coverage decisions and 38.4% of procedure coverage decisions were “more restrictive”: imposing more clinical restrictions or step restrictions relative to FDA label or clinical guidelines; or coverage that places a medication on an unfavorable tier. At a high level, the research demonstrates that payers restrict non-medication therapies more.

The findings demonstrate that payer evaluation and coverage of pharmaceuticals and medical procedures may differ independent of their clinical benefit. Therapy access depends on factors other than cost and clinical benefit, suggesting potential health care system inefficiency.

In their paper, the researchers also note that medications covered under the pharmacy benefit may have rebates, while therapies covered under the medical benefit typically do not; and that medications included in their analysis were particularly likely to have rebates. This could have caused the researchers to underestimate the value of self-administered medications, they caution.

“If our analysis had included all medications in each therapeutic class, including the lower volume medications that are less likely to receive rebates, our analysis might have shown that coverage of medications is less favorable than what we did find. In short, our results may be biased toward finding favorable coverage of self-administered medications,” they write.

The researchers conclude that use of different criteria and measures to influence access to different types of therapies, or access to similar therapies covered under medical and pharmacy benefit policies, may introduce inconsistencies and inefficient care.