Navigation Links
New Study Probes Stakeholder Attitudes on Ethics and Fairness of Cost-Sharing To Steer Appropriate Medication Use

WASHINGTON, Feb. 8, 2017 /PRNewswire-USNewswire/ -- Patients who have the same condition sometimes pay different out-of-pocket costs for their medications, but when is this differential fair? Payers, patients, employers and researchers identified five principles for when it is less acceptable for patients with the same condition to have different costs, according to a new study published in the Journal of Managed Care & Specialty Pharmacy.

When patients have out-of-pocket costs through copays or coinsurance, payers are able to better manage costs and encourage more efficient use of health care resources. However, cost-sharing mechanisms are typically based on the cost of the medication, not whether the treatment is medically appropriate for the patient. This structure can lead to intended and unintended impacts on adherence, costs and health outcomes.

Continue Reading
The National Pharmaceutical Council's latest research examines when it is less acceptable for patients to face higher cost-sharing.
The National Pharmaceutical Council's latest research examines when it is less acceptable for patients to face higher cost-sharing.

Patients with the same or similar condition may need different treatment options due to their genetic characteristics, comorbidities, socioeconomic factors or disease severity; therefore, patients may have medications on different formulary tiers and varying out-of-pocket expenses. The circumstances under which patients respond to treatment often vary. One patient may have a successful response to a lower-cost treatment, while another may need a more expensive treatment with a higher out-of-pocket cost for the same condition due to biology or genetics. 

To examine the issue, the National Pharmaceutical Council (NPC) convened an expert roundtable. Researchers initiated the discussion with a review of white papers addressing ethical, actuarial and legal issues and perspectives of representatives from patient, payer and employer communities. 

"We sought perspectives from the expert roundtable to help determine when it is acceptable to have variations in the costs patients with the same condition face," said Jennifer Graff, PharmD, Vice President of Comparative Effectiveness Research at NPC. "These discussions are important in achieving the fundamental goal of cost-sharing strategies–aligning costs to the most appropriate medical care."

The panel reviewed four case studies to determine how to optimally distribute the financial burden across patients, all plan members or employers, and how to address existing barriers to align out-of-pocket costs with medically appropriate treatments. The cases included use of step therapy for rheumatoid arthritis, treatment based on diagnostic test results for cystic fibrosis, patient preference for a treatment due to potential side-effects among patients with fibromyalgia, and patient preference for the route or frequency of administration for an osteoporosis treatment.

Panelists determined the following five guiding principles that detail when it is less acceptable for patients to have different out-of-pocket costs for the same or similar conditions:

1) "Try and Fail" is important: If the initial lower-cost therapy is unsuccessful, patients should have access to higher-cost therapy and lower out-of-pocket costs. This is also known as "reward the good soldier."

2) Benefits are certain and significant: If there is high confidence the health benefits of a treatment are significant, then financial barriers should be lowered.

3) Costs must align with benefits: If the treatment costs are balanced with better effectiveness and safety, then cost sharing should be lower.

4) Don't penalize patients for "bad luck": If patients need higher-cost treatment based on their biology or genetics, then cost-sharing should be reduced.

5) Lower, but do not eliminate differences in out-of-pocket costs: Cost-sharing differences incentivize trying lower-cost treatments first, but big jumps in costs for patients should be avoided.

"It can be challenging for employers to manage health care costs when their employees require higher-cost treatments," Cheryl Larson, Vice President of the Midwest Business Group on Health. "Employers are seeking evidence-based approaches to support or justify their health care costs. These principles create useful parameters for employers to consider as they select health benefits and make investments to ensure they maintain a healthy, satisfied and productive workforce."

With the health care industry moving from volume- to value-based care, the fairness and incentive to follow appropriate care pathways while keeping out-of-pocket costs low is taking center stage.

"For stakeholders involved in benefit design to succeed in incentivizing the right care, a one-size-fits-all approach won't deliver that," said Helen Sherman, PharmD, Chief Pharmacy Officer at Solid Benefit Guidance. "The panelists agreed that cost-sharing is appropriate in the right situations, but when a treatment is proven and medically necessary, a patient's bad luck is not one of them. The solutions outlined in this paper deliver smart guardrails that, if applied, can help improve the care plans provide and patients receive."

This study provides a broader look at the issues addressed in the NPC-supported white paper, "Exploring 'Dynamic' Cost-Sharing Models in Value-Based Insurance Design."

About the National Pharmaceutical Council
The National Pharmaceutical Council is a health policy research organization dedicated to the advancement of good evidence and science, and to fostering an environment in the United States that supports medical innovation. Founded in 1953 and supported by the nation's major research-based pharmaceutical companies, NPC focuses on research development, information dissemination and education on the critical issues of evidence, innovation and the value of medicines for patients. For more information, visit and follow NPC on Twitter @npcnow.

To view the original version on PR Newswire, visit:

SOURCE National Pharmaceutical Council
Copyright©2017 PR Newswire.
All rights reserved

Related medicine technology :

1. Global Market Study on Bone Glue: Rising Adoption of Bone Glue for Orthopedic Surgeries Expected to Boost Demand for Bone Glue over the Forecast Period
2. InDex Pharmaceuticals Enters Agreement With CRO for the CONDUCT Study
3. New Study Characterizes Detection of Hydrocodone and Morphine as Metabolites of Codeine in Oral Fluids
4. Fostamatinib Study Results Continue to Trend Positive
5. Study Highlights Keys to Creating a High-Value Medical Affairs Function in a Changing Healthcare Environment
6. Foresee Pharmaceuticals Announces Top-Line Results from Phase 3 Registration Study in Advanced Prostate Cancer
7. Study Shows Improved Outcomes With NephroCheck Test For Risk Assessment Of Acute Kidney Injury And KDIGO Intervention
8. Sanifit Announces Enrollment of First Patient in CaLIPSO - a Phase IIb Study for the Treatment of Cardiovascular Calcification in End-Stage-Renal-Disease Patients on Haemodialsis
9. Dermata Therapeutics, LLC Announces Initiation of Treatment in a Phase 2 Acne Rosacea Clinical Study
10. New First-of-Its-Kind Study Shows Growing Share of Medicine List Prices Going to Rebates and Supply Chain
11. Global Market Study on Precision Medicine: Drug Discovery Technology Segment Estimated to Witness 0.1% Decline in Market Share Between 2016 and 2024
Post Your Comments:
(Date:9/22/2017)... Sept. 22, 2017 AVACEN Medical (AVACEN) announced ... now successfully helping those with the widespread pain associated ... diagnosed Amanda in Essex, England ... my hair, experiencing no sleep at all, tremendous pain, ... I cannot recommend [the AVACEN 100] enough, how this ...
(Date:9/18/2017)... Mich. , Sept. 18, 2017  PMD Healthcare ... Specialty Pharmacy of Kalamazoo, Mich. , ... hub service that expedites and streamlines patient and provider ... PD 2.0, and wellness management services.  ... device used to measure lung function for a variety ...
(Date:9/12/2017)... 12, 2017   EcoVadis , the leading platform for environmental, social ... annual edition of its Global CSR Risk and Performance Index. The report ... based on Scorecard Ratings that analyzed nearly 800,000 data points across the ... ... ...
Breaking Medicine Technology:
(Date:10/13/2017)... ... October 13, 2017 , ... The Visiting Nurse Association (VNA) of Somerset ... of specialty vendors and unique items from across the nation, this holiday-themed event will ... services offered by the VNA. The boutique will be open Saturday, November 4 ...
(Date:10/13/2017)... ... , ... Talented host, actor Rob Lowe, is introducing a ... episode of "Success Files," which is an award-winning educational program broadcasted on PBS ... in-depth with passion and integrity. , Sciatica occurs when the sciatic nerve in ...
(Date:10/12/2017)... ... October 12, 2017 , ... First Healthcare Compliance (FHC), an ... showcase a range of technology and learning solutions at the 68th Annual American ... to be held October 14–18, 2017 at the Mandalay Bay Resort in Las ...
(Date:10/12/2017)... ... October 12, 2017 , ... IsoComforter, Inc. ( ... today the introduction of an innovative new design of the shoulder pad. The ... get maximum comfort while controlling your pain while using cold therapy. By utilizing ice ...
(Date:10/12/2017)... ... October 12, 2017 , ... Dr. Parsa Mohebi, the ... medical article to the newly revamped Cosmetic Town journal section, featuring ... transplant procedure known as Follicular Unit Extraction (FUE). , Dr. Mohebi ...
Breaking Medicine News(10 mins):