How effectively did payers present “truthful” entry insurance policies? Based mostly on an latest ICER report titled “Assessment of Barriers to Fair Access“, the headline figures appear fairly good:
Total charges of concordance with ICER’s standards had 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 as if very reasonable entry. Nevertheless, digging a bit deeper, reveals that sufferers do nonetheless face important hurdles.
The desk beneath reveals that whereas 70% of medication acquired truthful entry, that is based mostly on the 84 medicine that had been truly coated by insurance coverage. Of the 342 medicine evaluated, nonetheless, 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 could be thought-about truthful based mostly on ICER’s standards solely 17.4% (n=59 out of 352) of the time.
Payers had 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 symbolize 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 via 2 not to mention 3 therapies, nonetheless, is very problematic for a lot of ailments.
In brief, do US business payers present truthful entry? The reply to this query probably is dependent upon the attention of the beholder.