How effectively did payers present “honest” entry insurance policies? Based mostly on an latest ICER report titled “Evaluation of Obstacles to Honest Entry“, the headline figures appear fairly good:
Total charges of concordance with ICER’s standards have been 70% for price sharing of fairly-priced medicine, 96% for medical eligibility standards, 98% for step remedy, and 100% for supplier restrictions
At first look, this looks like very reasonable entry. Nevertheless, digging a bit deeper, exhibits that sufferers do nonetheless face important hurdles.
The desk under exhibits that whereas 70% of medication obtained honest entry, that is based mostly on the 84 medicine that have been really lined by insurance coverage. Of the 342 medicine evaluated, nevertheless, most medicine (75%, 258 out of 342) weren’t lined in any respect. De facto, this imply that price sharing was 100%! If we embrace each lined and non-covered medicine within the evaluation, then price sharing can be thought-about honest based mostly on ICER’s standards solely 17.4% (n=59 out of 352) of the time.
Payers have been extra more likely to comply with ICER guidelines with respect to medical eligibility and limitations on step remedy, and supplier restrictions. Nevertheless, a few of these equity standards signify a comparatively low bar. As an example, ICER states that they’ve applied “a most variety of three steps allowed for a step remedy coverage to stay concordant with honest entry standards”. Requiring sufferers to step by way of 2 not to mention 3 therapies, nevertheless, is very problematic for a lot of ailments.
Briefly, do US business payers present honest entry? The reply to this query doubtless relies on the attention of the beholder.