How nicely did payers present “fair” entry insurance policies? Based on an latest ICER report titled “Assessment of Barriers to Fair Access“, the headline figures appear fairly good:
Overall charges of concordance with ICER’s standards had been 70% for value sharing of fairly-priced medicine, 96% for scientific eligibility standards, 98% for step remedy, and 100% for supplier restrictions
At first look, this looks as if very reasonable entry. However, digging a bit deeper, exhibits that sufferers do nonetheless face vital hurdles.
The desk under exhibits that whereas 70% of medicine acquired honest entry, that is based mostly on the 84 medicine that had been truly coated by insurance coverage. Of the 342 medicine evaluated, nonetheless, most medicine (75%, 258 out of 342) weren’t coated in any respect. De facto, this imply that value sharing was 100%! If we embody each coated and non-covered medicine within the evaluation, then value sharing could be thought of honest based mostly on ICER’s standards solely 17.4% (n=59 out of 352) of the time.
Payers had been extra more likely to observe ICER guidelines with respect to scientific eligibility and limitations on step remedy, and supplier restrictions. However, a few of these equity standards characterize a comparatively low bar. For occasion, ICER states that they’ve applied “a maximum number of three steps allowed for a step therapy policy to remain concordant with fair access criteria”. Requiring sufferers to step by way of 2 not to mention 3 therapies, nonetheless, is extremely problematic for a lot of illnesses.
In quick, do US industrial payers present honest entry? The reply to this query possible is dependent upon the attention of the beholder.