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.