Are well being insurers offering truthful entry? – Healthcare Economist


How effectively did payers present “truthful” entry insurance policies? Primarily based on an current ICER report titled “Evaluation of Obstacles to Truthful Entry“, the headline figures appear fairly good:

General charges of concordance with ICER’s standards have been 70% for value 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 particularly reasonable entry. Nonetheless, digging a bit deeper, exhibits that sufferers do nonetheless face important hurdles.

The desk beneath exhibits that whereas 70% of medicine acquired truthful entry, that is primarily based on the 84 medicine that have been truly coated by insurance coverage. Of the 342 medicine evaluated, nevertheless, most medicine (75%, 258 out of 342) weren’t coated in any respect. De facto, this imply that value sharing was 100%! If we embrace each coated and non-covered medicine within the evaluation, then value sharing can be thought of truthful primarily based on ICER’s standards solely 17.4% (n=59 out of 352) of the time.

Payers have been extra more likely to observe ICER guidelines with respect to medical eligibility and limitations on step remedy, and supplier restrictions. Nonetheless, a few of these equity standards characterize 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 truthful entry standards”. Requiring sufferers to step via 2 not to mention 3 therapies, nevertheless, is very problematic for a lot of ailments.

Briefly, do US industrial payers present truthful entry? The reply to this query probably is determined by the attention of the beholder.


Leave a Comment