Aggressive Cost-Sharing Forces Some Patients to go Without


Higher price tags and greater cost-sharing in specialty medicine may force patients to forego, delay or reduce treatment, a study shows.

Specialty drugs have long been associated with higher prices and greater patient cost-sharing, but a new study delved into whether current cost-sharing requirements impact a patient’s likelihood to forego, delay or reduce specialty drug-adherence.

In an article from the Perelman School of Medicine published in the March 2016 American Journal of Managed Care, researchers evaluated existing literature to determine whether cost-sharing impacted the use of non-drug medical services, health outcomes and spending.

Currently, individuals using specialty drugs comprise between 1 percent and 5 percent of patients and account for $95 billion in drug spending – roughly 29 percent of all prescription drug expenditures nationwide. Drugs for cancer and autoimmune conditions, such as rheumatoid arthritis (RA) or multiple sclerosis (MS), are responsible for two-thirds of that price tag. In fact, patients frequently pay co-insurance equal to between 30 and 50 percent of the drug cost.

Researchers conducted a literature review, analyzing Medline-indexed studies in OVID from 1995 to 2014 to determine the cost-sharing impact. They identified 19 studies focused on specialty drugs for RA (8), MS (9), and cancer (8). The studies addressing RA touched on prescription abandonment (2), initiation (4), adherence (3), persistence/discontinuation (3), and drug spending (1).  [[{"type":"media","view_mode":"media_crop","fid":"47684","attributes":{"alt":"©Burlingham/","class":"media-image media-image-right","id":"media_crop_301604290932","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5642","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©Burlingham/","typeof":"foaf:Image"}}]]

According to these studies, if cost-sharing doubles, there’s a 5 to 9 percent drop in the number of RA patients taking a specialty drug for the first time (initiation). There’s also a 3.8 percent reduction in continuation if cost-sharing doubles after they start. Existing research also revealed non-initiation, non-compliance or abandonment are less likely among patients with life-threatening conditions, such as cancer, than among those with auto-immune disease.

To help determine how best to address cost-sharing in the future, researchers suggested establishing policies that could offer patients additional protections against aggressive cost-sharing policies. Such measures could result in higher medication compliance and improved health outcomes.

Traditional three-tiered cost-sharing designs are seldom used by insurers and pharmacy benefit managers because there often few options in specialty medicine. Instead, they use utilization management (UM) tools, such as prior authorization and quantity limits.

"Nevertheless, growing pressure to control spending has led insurers to increasingly place self-administered specialty drugs on new, separate “specialty tiers,” the authors wrote.

Specialty tiers are usually associated with a co-insurance that can be as high as 30-50 percent of the drug cost. But cost-sharing is typically associated with fixed co-payments of increasing amounts for generics, preferred brands and non-preferred brands.

“There is a critical need for methodologically rigorous research to further evaluate whether the aggressive cost-sharing arrangements found in the current marketplace may cause patients to forego, delay or decrease adherence to specialty drugs and whether that results in poor health outcomes and higher total spending,” the authors wrote.



Jalpa A. Doshi, PhD; Pengxiang Li, PhD; et. al.

"Impact of Cost Sharing on Specialty Drug Utilization and Outcomes: A Review of the Evidence and Future Directions,"

AJMC. Published online March 17, 2016. (Am J Manag Care. 2016;22(3):188-197)   

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