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Policy Improvement Areas to Reduce Financial Hardship


Elected officials and others who affect policy know that cost-sharing and out-of-pocket costs are issues in healthcare, but they don’t truly understand the issues, said panelists during a policy discussion on ways to improve access and reduce financial hardship during the Cost-Sharing Roundtable.

Elected officials and others who affect policy know that cost-sharing and out-of-pocket costs are issues in healthcare, but they don’t truly understand the issues, said panelists during a policy discussion on ways to improve access and reduce financial hardship during the Cost-Sharing Roundtable, co-hosted by the Patient Access Network Foundation and The American Journal of Managed Care®.

Anna Hyde, vice president of advocacy and access at the Arthritis Foundation, estimated that just 15% to 20% of people who affect policy actually understand those issues. They might be hearing about these issues from their constituents, but she wonders if they really understand the problems patients are facing.

Kavita Patel, MD, nonresident fellow of economic studies at the Center for Health Policy at the Brookings Institution, outlined the recent budget deal to highlight what Hyde was mentioning. The budget deal included a provision to close the donut hole in Medicare Part D, but the way it is structured may backfire and most of the benefit goes to the Part D plans before the beneficiaries.

“Awareness is high, but the ability to do something about it and be thoughtful, and see the implementation through is very low,” Patel explained.

Emily Gibb, MA, interim vice president of public policy at GSK, pointed out it’s important to segment out policy makers. Someone who is elected in Congress has a different responsibility than someone at CMS.

“The competing priorities that exist in Congress certainly prevent a deeper level of awareness sometimes and a call to action than we need,” she said. And at the state-level there is a greater understanding.

However, Ed F. Haislmaier, the Preston A. Wells Jr senior research fellow at the Institute for Family Community, and Opportunity at The Heritage Foundation, challenged the idea that underinsurance is a problem. He noted that cost-sharing is a tool that may or may not work depending on the population being targeted. What’s important is knowing what behaviors policy makers are trying to encourage or risks they are trying to avoid.

He also highlighted what he considered the failing of the Affordable Care Act. He said the health law suffered from “policy schizophrenia.”

“On the one hand, you have obviously a very clear concern with what you term underinsurance… But then there is also the Cadillac tax,” which is trying to address people who are overinsured, Haislmaier said.

Patel also discussed adherence issues that result from high cost-sharing. She explained that in oral therapeutics for cancer, which can be lifesaving, there is low adherence when there are higher out-of-pocket costs.

“Adherence is that holy grail where if we could understand how to make people more adherent and if we could just throw money at the problem and that would solve it, people would,” Patel said. “But, unfortunately, it’s not just a matter of out-of-pocket costs. Out-of-pocket costs are just 1 piece of it.”

And as people age, adherence decreases not only because they are on more drugs, but also new research is showing strong correlations between insurance benefit design complexity and low adherence. Doctors—herself included, she admitted—are becoming more and more desensitized to insurance issues and what insurance their patients have.

Hyde and Gibb both discussed financial assistance needs. The Arthritis Foundation has a helpline and the number 1 call it gets is for people on Medicare who can’t afford their co-pays for their prescription drugs, Hyde explained. Gibb added that GSK does a lot of work in the patient assistance world, and its reimbursement resource center gets the most calls from patients who are 65 years or older who need assistance with their medications.

The panelists then discussed value-based payments. While the current administration might not be as fond of accountable care organizations as the Obama administration was, there is still interest in trying new payment models out through Center for Medicare and Medicaid Innovation continue payment reform demonstrations, Patel said.

“There is no reason they can’t go after Part D through those authorities in those models with those physicians and beneficiaries who are currently in those models,” Patel said.

The problem, she added, is that the Oncology Care Model has been the only value-based payment model that is getting timely, reliable Part D data.

The panelists closed with a discussion on the need for better health financial literacy. From a chronic disease perspective, some patients find it difficult enough managing their disease and getting through the day, let alone taking the time to understand the nuances of their benefits, explained Hyde. Ultimately, though, conversations the Arthritis Foundation has had with stakeholders has made it clear that “patients need to choose the right health plan.”

Patel expressed disbelief that there isn’t a better way to teach patients better health financial literacy.

“I don’t understand why we’re not making better, I don’t know, Netflix shows about how to read your explanation of benefits,” she said. “I feel like we’re doing these little cosmetic, marginal things and it’s the elephant in the room.”

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