Access to drug, insurance coverage data improving

A new report attempts to pierce the veil of drug pricing and insurance coverage, an area that is marked by a lack of industry data and a surfeit of horror stories from consumers. Overall, the report noted the limitations of its conclusions but found that most payers seemed to be providing fair access for the drugs in the analysis, based on the available data.

The first annual “Barriers to Fair Access” report was released by the Institute for Clinical and Economic Review (ICER), a nonprofit research group that explores the effectiveness and value of prescription drug pricing.

The report evaluated 15 of the largest commercial formularies for prescription drugs in the U.S. to determine how they matched fair access criteria developed by ICER. With 28 drugs evaluated, the researchers said there was data showing a high level of concordance with the fair access criteria developed for the study.

“In our assessment, we found that most of the payer policies available to us were structured appropriately in a way to support many key elements of fair access,” said ICER’s President Steven D. Pearson, MD, MSc. “But there are significant caveats to our findings. Among the most important are these three: we couldn’t evaluate all the criteria that are essential for fair access; not all policies were available to us even for the criteria we were able to evaluate; and we could only evaluate the content of the policies, not their implementation. These limitations mean that our report does not negate the experience of many patients and clinicians who have struggled to get fair access, particularly when the barriers are related to poor implementation that can lead to prolonged delays and unnecessary administrative burden.”

Murky data; troubling anecdotes

The report started out by noting that data in this area is difficult to obtain, with gaps in information in some cases, and complexities in cost-sharing and coverage policies that are not well-documented in the data that does exist. Step therapies—where patients are required to try lower-cost therapies that may not be effective before being approved for more expensive therapies, was noted as a particular challenge.

“This assessment was not able to evaluate critical elements of how these coverage policies are administered in the real world, including their level of documentation burden, how transparent and efficient the prior authorization process is to clinicians and patients, and how responsive payers are to requests for medically appropriate exceptions,” the report said. Although the overall findings suggested a substantial concordance with fair access criteria overall, this lack of real-world data should be considered when putting the results in context, the researchers added.

The report included several anecdotal stories from consumers that outlined the problems created by strategies such as step therapies in the real world. “My insurance company would only approve treatments in a certain order, like steps up a ladder,” one patient said. “First, I had to use a chemotherapy drug that gave me a severe reaction. Then, my doctor had to fight to get me started on an injected treatment, but this medicine only worked for a short period of time before it stopped helping me… My mom spends hours on the phone fighting to get my treatments approved by the insurance company. Now that my current treatment is failing, my doctor is already talking about how we may have to fight the insurance company for it.”

Consumers stories like this suggest that drug pricing and approval policies are still a long way from “fair” for many patients.

The bigger picture: A need for more transparency

The researchers acknowledged that emotional consumer stories may outshine the data around prescription drug coverage—and that they lack context in the complicated world of pharmaceuticals and therapies.

The report concluded that all parties may have their own legitimate points of view, but that one possible way to address the conflicts is to provide more transparency. “Perhaps the most salient conclusion from this assessment is that there should be greater transparency regarding how insurers frame and implement their coverage policies,” the study said. “Transparency certainly for affected patients and their clinicians, but also for the broader research community and the public…Only with greater transparency across the entire industry will payers be able to demonstrate fully their commitment to the appropriate application of evidence to insurance coverage.”

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https://icer.org/news-insights/press-releases/icer-publishes-first-annual-assessment-of-barriers-to-fair-access-within-us-commercial-insurance-prescription-drug-coverage/