Experts Envision “Precision” Benefit Design

Health plans often use different levels of cost sharing to drive patients toward one medication over another. But is this practice fair, ethical or effective in producing positive outcomes for patients? The answer, according to a recent National Pharmaceutical Council webinar panel, all depends.

“Skin in the Game”

Research shows that when patients are asked to pay more out of pocket, they do decrease their use of inappropriate health care. But they also decrease their use of appropriate care, including high-value medications and services.

Mark Fendrick, MD, of the University of Michigan’s Center for Value-Based Insurance Design says this could be a problem, particularly when chronically ill or vulnerable patients opt out of necessary care due to cost. “’Skin in the game’ is one thing,” Dr. Fendrick said of cost sharing, “Taking out a second mortgage to get a needed test…is something altogether different.”

Precision Benefit Design

Panelists rallied instead around a concept dubbed “precision benefit design.” Just as precision drugs are tailored to a patient’s genetic profile, these benefit designs would tailor coverage based on the value of a given treatment. Patients seeking high-value treatments would face less onerous cost sharing and fewer administrative hurdles, such as prior authorization.

Dr. Fendrick described the approach as applying “clinical nuance.” It would be a departure from current benefit designs, where patients might pay the same for a drug with little proven clinical benefit as they would for a targeted treatment that boasts a 90% success rate, Dr. Fendrick explained.

Access to High-Cost, High-Value Treatments

The parallel to precision medicine is apt. As the rise in targeted therapies introduces more high-cost, high-value treatment options, health insurers may have to fundamentally reconsider their coverage approach. Helen Sherman of Solid Benefit Guidance acknowledged the challenges of insurance coverage in the age of precision medicine. She agreed that co-pays should be based on the value of a medication but emphasized health plans’ need for more research and data.

Precision benefit designs could also meet the needs of employers, explained Cheryl Larson of the Midwest Business Group on Health. “Employers want a healthy, robust workforce,” Larson explained. Designs that discourage patients from getting necessary care can stand in the way of that goal.

The experts’ consensus centered on a key point: Differential cost sharing should encourage patients to pursue high-value treatments and deter them from less effective options. But who determines that value – and how – remains to be seen.

For more on differential cost sharing, see the National Pharmaceutical Council’s “Does a One-Size- Fits-All Cost-Sharing Approach Incentivize Appropriate Medication Use?”.

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