Considering Efficiency and Fairness in the Design of Prescription Drug Benefits

Is it appropriate to charge a patient with a higher co-pay for a particular drug if his or her biological makeup requires the use of a treatment that is on a higher-tier of the prescription drug benefit?

This is one of the questions National Pharmaceutical Council (NPC) Chief Science Officer Robert W. Dubois, MD, PhD, tackled during his presentation, "Considering Efficiency and Fairness in the Design of Prescription Drug Benefits: Seeking a Balanced Approach to Improve Patient Access to Medically Appropriate Medication and Manage Drug Costs," on Monday, June 15, 2015, 8:00 am CDT, at the AcademyHealth's Annual Research Meeting at the Minneapolis Convention Center in room 200 A/B.

The session presented ethical, legal, economic and practical considerations for different drug benefit designs and explored the key factors in benefit design that allow for co-pays to be based on clinical appropriateness.

Dr. Dubois was joined by Russell Teagarden, independent consultant, and Cheryl Larson, vice president, Midwest Business Group on Health. The panelists, representing patient, employer and payer stakeholder perspectives, discussed how to balance cost containment with medically appropriate access.

Tiered pharmacy benefit designs are becoming increasingly prevalent. Higher tiers usually correspond with higher patient co-pays or coinsurance and with other benefit design strategies, such as prior authorization and product utilization management.

In many cases, patients have individual biological characteristics that indicate if a higher tier treatment will be the most effective for them. However, these patients are required to pay often significantly higher out-of-pocket costs than those patients whose biological characteristics indicate efficacy of lower tier treatments.

Dr. Dubois and the panelists raised the issues of fairness and treatment efficiency related to these differential co-pays, and discussed whether these benefit designs take into account the underlying reasons for individual patient treatment decisions that lead to higher tier prescriptions.

Also be sure to check out these poster and podium presentations of NPC-sponsored research:

• Heterogeneity of Treatment Effects: Current Trends in Analysis and Reporting
  Monday, June 15, 2015, 9:45 am - 11:45 am CDT (Poster #852)
• State All-Payer Claims Databases (APCD): Will Limited Access Hamper Research on System-Wide Healthcare Quality, Cost, and Outcomes?
  Monday, June 15, 2015, 6:45 pm - 8:15 pm CDT (Poster #1140)
• Improving the Ability to Evaluate Comparative Effectiveness Research Study Designs through an Online Educational Program
  Tuesday, June 16, 2015, 10:30 am - 11:15 am CDT (Room 200 E/F)