Segment 7 - Patient Cost Sharing and Medication Adherence

Dr Fendrick says that while indication and utilization of major innovations should be widespread, there are still questions of who will pay for them. As mentioned, plan sponsors (employers) are only 1 option.

Currently, some specialty pharmacy design has all same-tier drugs at the same level of cost sharing and co-insurance. Dr Fendrick suggests that value-based insurance design (V-BID) may be useful. He says for specialty pharmaceuticals, and especially those that bring about cures—whether for cancer or infectious disease like hepatitis—providers could consider the clinical nuance of cost sharing. This would allow some patients to make out-of-pocket contributions that are less than those they would make toward equally expensive drugs that never cure and/or may only extend life by a few months.

Dr Miller says it’s an interesting concept, especially because as Dr Fendrick notes, Express Scripts has been using V-BID for small-molecule drugs. Such innovative cost-sharing models can be useful for driving adherence.

The panelists go on to discuss what a reasonable out-of-pocket maximum might look like, and they decide that it probably would not be zero. Employers are looking at an estimated $1500 out-of-pocket maximum. While this may or may not be the right number, even crucial therapies are likely to have some costs for patients.

Dr Fendrick says initiatives such as Choosing Wisely demonstrate how benefit design tailored to specific conditions and services may in fact serve populations better than general plans that are recommended to everyone.