Prior authorization, forms and patient cost sensitivity can greatly influence doctors’ prescribing patterns, said Scott Howell, Novartis chief strategy officer and lead author of the study.
“The existing evidence suggests two things: first, that drug utilization management has reached a level that is no longer aligned with clinical guidelines,” he said, citing a American Medical Association Survey It found that 32% of physicians believe that prior authorization criteria rarely or never align with medical guidelines. “Second, they also found that managing drug use contributes to treatment delays, suboptimal drug use, drug abandonment, and worse health outcomes.”
Copayment coupons, coverage adjustments, and administrative support programs can limit the use of ineffective and expensive drugs, which can reduce health care costs. However, the healthcare system is caught in a vicious cycle: Manufacturers increase the list price and payers tighten access restrictions, leading to further price increases and even more onerous limitations, the researchers said.
“This is what has led to the escalation cycle that we are experiencing today, where we have higher prices and lower access, which is the opposite of what we want: a system that promotes price moderation and great access for patients. Howell said. “We should work together to reduce the escalation of this so-called ‘war of all against all’ by linking value-based drug prices with better access for patients.”
That “war of all against all” stems from misaligned incentives, he said. Health plans decide whether to reduce copayments based on the size of reimbursement that manufacturers offer to pharmacy benefit managers. While overall net drug prices have fallen for several years as reimbursements increased, higher reimbursements have inflated list prices and complicated insurance coverage, Howell said.
Manufacturers have tried to reduce the burden of access restrictions through administrative support programs known as “central services.” Manufacturers spend about $ 5 billion to $ 6.7 billion on those programs a year, according to the study.
But those centers often force patients to use specific pharmacies that are affiliated with the manufacturer, which means that the local pharmacy or specialty pharmacy in a health system cannot fill prescriptions, Fox said.
Drug makers also spend between $ 13 billion and $ 15 billion a year on direct financial support, including co-pay discount cards, the analysis found. But Medicare patients cannot use copay cards. In addition, some drug manufacturers have funneled bribes through supposedly independent charities that paid co-payments to patients.
As for ways to simplify drug utilization management, Praluent, the cholesterol drug from Sanofi and Regeneron, could serve as a useful example, the researchers said.
The manufacturers agreed to charge a net price close to the Institute for Clinical and Economic Review benchmark. In return, Praluent had simpler prior authorization criteria and significant reductions in cost-sharing requirements.
Prices should be tied to access, the researchers said. Individual manufacturers could voluntarily set prices based on benchmarks proposed by independent organizations. Those value-based pricing would be tied to access, where payers bring drugs to patients who need them most.
“Patients will have easier and more affordable access to the drugs they need; providers will spend fewer hours navigating insurer requirements; insurers will pay less for drugs and need fewer systems to manage access; and biopharmaceutical companies will be able to focus their resources on developing the most innovative treatments, “said Howell.