Patient Assistance Infographic Copayment AssistanceĬopayment assistance is generally targeted to individuals with commercial coverage these programs cannot be used by individuals enrolled in Medicare, Medicaid, or other federal health care programs. Patient assistance may be delivered in several forms, including copayment assistance cards (commonly referred to as “copay cards,” “discount cards,” or “savings cards”), manufacturer assistance programs, and grants from charitable patient assistance foundations. Patient assistance programs frequently serve to fill the void, reducing the risk of “financial toxicity” and cost-related nonadherence. 15 At present, however, V-BID is not common for high-cost medications, and patients are frequently exposed to high costs for clinically-indicated medications. 14 Ideally, benefit designs would reflect V-BID principles for all services and medications, through tools such as dynamic cost-sharing. Most payers and purchasers that have implemented V-BID have limited their efforts to relatively small populations and a small subset of high-value services and medications. 12 V-BID incorporates clinical nuance, “recognizing that the clinical benefit of a specific service or therapy depends on who receives it, who provides it, and where and when in the course of disease the service or therapy is provided.” 13 These clinically nuanced benefit designs have repeatedly been shown to reduce cost-related non-adherence for many types of conditions. Such an approach encourages the use of high-value care while maintaining or strengthening incentives to avoid wasteful spending. Value-based insurance design (V-BID) entails better aligning of out-of-pocket cost-sharing with the value of the underlying service – i.e., lowering cost-sharing for high-value services and/or increasing cost-sharing for low-value services. Historically, however, cost-sharing has been “one-size-fits-all,” and has failed to distinguish between high- and low-value clinical services and therapies. 8–11Ĭost-sharing is a useful tool for payers and purchasers to encourage prudent use of health care dollars. 5,6,8,9 Research suggests that cost-related underuse of evidence-based services disproportionally impacts poorer Americans and those with chronic conditions. 4,7 Increased acute care utilization and poorer health outcomes may result. 4–6 In response to across-the-board increases in cost-sharing, many studies find that patients reduce use of both high- and low-value care in similar proportions. Patients subject to greater cost-sharing tend to reduce use of services and medications – and the greater the cost-share, the greater the corresponding reduction in service use. 3Ĭost-sharing at these levels is associated with many deleterious consequences. 3 For Medicare Part D beneficiaries using common treatments for rheumatoid arthritis, Hepatitis C, and multiple myeloma, out-of-pocket cost-sharing frequently surpasses $4,500, $6,500, and $11,500 respectively. Most Medicare Part D beneficiaries taking a single specialty drug will pay no less than $2,000 over the course of one year. ![]() In 2016, more than 25% of Medicare beneficiaries spent 20% or more of their income on out-of-pocket health care costs, 2 with a significant share of this spending devoted to coinsurance of 25-33% for specialty medications. The average copay or coinsurance for a fourth-tier drug in employer-sponsored coverage was $102 in 2016. 1 Even after any applicable deductible has been satisfied, patients are often liable for high copayments and coinsurance. The average deductible for employer-sponsored single coverage increased by more than 250% between 20, and is now nearly $1,500. Precision Patient Assistance Programs to Enhance Access to Clinically Indicated Therapies: Right Drug, Right Time, Right Cost-Share Cost-Sharing and its ConsequencesĬonsumer cost-sharing for medical care and medications is high and getting higher. Precision Medicine Needs Precision Benefit Design. ![]()
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