Patients Face Rising Costs, Varied Coverage

New research paints a troubling picture of patient access to prescription medication.  

A report from the Kaiser Family Foundation shows that the amount patients pay out-of-pocket for their health care through employer-sponsored plans rose 54 percent between 2006 and 2016.  The average deductible rose from $303 to more than $1,200, and patients’ payments toward those deductibles rose by 176 percent.  The increase far outpaced wage growth.

Insurers’ costs also grew, but by only 49 percent.  

Does this greater cost-sharing mean improved access for patients?  Not necessarily.

Another study, published in July’s “Health Affairs,” reveals widespread variation in coverage and reimbursement for specialty drugs.  While the Food and Drug Administration’s indications make clear which drugs are approved to treat which conditions, health insurers’ decisions about which drugs to cover for which conditions – and to what extent – vary widely.  

Of the coverage decisions that researchers analyzed:


  • Only 52% were consistent with the drug’s FDA indication
  • 73% required patients to “fail first” on an insurer-preferred drug
  • 31% carried limitations about which physicians could prescribe them
  • 16% were limited to specific patient subgroups
  • 23% involved multiple coverage restrictions.


Claims information was derived from a Tufts Medical Center database of common specialty drug policies for 17 of the United States’ largest commercial health plans.

The study’s researchers explained that variations in coverage “have implications for patients’ access to treatment.” Meanwhile, the National Pharmaceutical Council said the findings underscore the need for more transparency about what evidence health plans use to determine coverage.  

The 21st century is widely heralded as a period of remarkable innovation and medical advancement.  But these data suggest it may also be the age of rising patient health care costs for increasingly diminished health care access.

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