What about payers offering “fair” access policies? According to a recent ICER report titled “Assessing Barriers to Equitable Accessthe title figure looks fine:
Overall agreement with ICER criteria: 70% cost sharing for fair-priced drugs, 96% clinical eligibility criteria, 98% step-by-step therapy, and 100% provider restrictions
At first glance, this seems like a pretty fair visit. Digging a little deeper, however, reveals that patients do still face significant hurdles.
The table below shows that while 70% of the drugs received fair access, this was based on the 84 drugs actually covered by insurance. However, of the 342 drugs assessed, the majority (75%, 258 of 342) were not covered at all. In fact, this means that the cost sharing is 100%! If we included both covered and non-covered drugs in the analysis, only 17.4% (59 of 352) of the cost-sharing was considered fair by ICER’s criteria.
Payers are more likely to comply with ICER rules on clinical eligibility and step-up treatment restrictions, as well as provider restrictions. However, some of these fairness standards represent relatively low standards. For example, ICER says they have implemented “up to three steps to allow for step-up treatment policies to align with equitable access standards.” However, requiring patients to step through 2 therapies, let alone 3, is a big problem for many diseases.
In short, are U.S. commercial payers offering fair access? The answer to this question may lie in the eye of the beholder.
