November 2014 Edition Vol.11, Issue 11

Patient Affordability: The Most Important Non-Clinical Attribute in Choosing Between Treatment Options

Patient Affordability: The Most Important Non-clinical Attribute In Choosing Between Treatment Options (continued)

Our survey showed that 27% of the commercial lives managed by the surveyed payers do not have an annual maximum out-of-pocket (MOOP). More than half of respondents reported a combined annual MOOP for medical and pharmacy benefits mean of $3,902. Without a MOOP limit in place, patients may experience financial hardship, especially patients with cancer who generally have a higher need for financial assistance. It is important for manufacturers to realize that regardless of benefit design, the mean MOOP still presents significant affordability issues for patients.

While many people enrolled in the healthcare exchange plans through the ACA in 2014, challenges to affordability to healthcare remain. OOP costs are not necessarily alleviated once a patient becomes insured. As widely reported, there are differences in premiums, deductibles and cost-sharing that result in highly variable levels of coverage and cost across patients. A comparison of the OOP costs for the first month of treatment with Zytiga ($6,837 per month)* by three state marketplace silver plans varies greatly by state. A patient enrolled in Arizona’s Aetna Classic plan would pay $3,669, while a patient in California’s Anthem Blue Cross Silver plan would receive the same treatment for $1,567, and Texas’ Blue Advantage Silver HMO would incur a $150 copay (Figure 2).

*Zytiga price retrieved from HIS Global Insight Inc.

While these exchange enrollees have the benefit of having a cap on their OOP costs, states with high integrated (combined medical and pharmacy) deductibles or high cost sharing for oncology products place great financial stress on patients. State-by-state cost sensitivity analysis needs to be considered by manufacturers to forecast prescribing attrition and abandonment, and this information could be used to inform adjustments to financial assistance programs.

States that have not expanded Medicaid under the ACA have created large “coverage gaps.” Nearly two out of three, or 5 million uninsured Americans earning between 50% and 100% of the FPL who would otherwise qualify for coverage under Medicaid expansion live in states that will not or have not yet decided to broaden the program. Because the intent of the ACA was to cover these individuals under Medicaid (the provision was struck down by the Supreme Court in 2012), subsidies for the marketplace plans are available only for those with incomes between 100% and 400% of FPL. Thus, these individuals have no financial support for healthcare. Over half of these uninsured patients in the “coverage gap” live in four states: Texas, Florida, Georgia and North Carolina. Of these, only Florida is currently considering participation in Medicaid expansion. The Medicare gap population will likely rely on manufacturer, charitable foundation and other financial assistance programs.

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