December 7, 2023

How effectively did payers present “truthful” entry insurance policies? Primarily based on an latest ICER report titled “Assessment of Barriers to Fair Access“, the headline figures appear fairly good:

General charges of concordance with ICER’s standards have been 70% for price sharing of fairly-priced medicine, 96% for scientific eligibility standards, 98% for step remedy, and 100% for supplier restrictions

At first look, this looks as if very reasonable entry. Nonetheless, digging a bit deeper, exhibits that sufferers do nonetheless face important hurdles.

The desk beneath exhibits that whereas 70% of medication obtained truthful entry, that is primarily based on the 84 medicine that have been truly 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 embody each lined and non-covered medicine within the evaluation, then price sharing could be thought-about 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 comply with ICER guidelines with respect to scientific eligibility and limitations on step remedy, and supplier restrictions. Nonetheless, a few of these equity standards characterize a comparatively low bar. For 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 by way of 2 not to mention 3 therapies, nevertheless, is very problematic for a lot of illnesses.

Briefly, do US business payers present truthful entry? The reply to this query possible depends upon the attention of the beholder.