A Dynamic Approach to Consumer Cost-Sharing for Prescription Drugs
The level of consumer cost-sharing for higher cost medication should be aligned with the clinical value – not solely the price – when lower cost alternatives do not produce the desired patient-centered outcomes.
Author: Fendrick, AM
Publication: Value-Based Insurance Design Center at the University of Michigan; funded by the National Pharmaceutical Council
Given the significant individual and population health gains that result from the appropriate use of prescription drugs, as well as the fiscal concerns pertaining to the escalation of health care expenditures, the development and implementation of patient-centered solutions that allow access to medications at an affordable cost are of critical importance.
This white paper, authored by the Value-Based Insurance Design Center at the University of Michigan and funded by the National Pharmaceutical Council, addresses how to improve access to medications via a "dynamic approach." The approach recognizes that “the level of consumer cost-sharing for higher cost medication should be aligned with the clinical value – not solely the price – when lower cost alternatives do not produce the desired patient-centered outcomes.”
Rather than punishing a patient who perfectly complies with the treatment steps required by the health plan but cannot safely take or does not respond to first-step therapy and requires higher-level treatment, a dynamic approach would instead lower the consumer cost-sharing obligation for higher-line treatment alternatives “only when the first-line therapy is contraindicated or is deemed ineffective at achieving the desired clinical outcome.”
Such a plan would still emphasize lower-cost therapies for initial use when “clinically appropriate,” but shifting to dynamic cost-sharing “enhances access to effective, clinically appropriate therapies, improves patient outcomes, aligns with quality-driven provider initiatives, and promotes efficient expenditures for the payer.”