Dr James Chambers Discusses Variability in Specialty Drug Coverage and Its Impact

A study found that out of hundreds of specialty drugs, only 16% were covered in the same way by 17 commercial payers in the United States, meaning that 84% of those specialty drugs had differing coverage, explained James D. Chambers, PhD, MPharm, MSc, associate professor, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center.

Transcript

How does specialty drug coverage from commercial payers vary throughout the country?

At the Center for the Evaluation of Risk in Health at Tufts Medical Center, we’ve actually developed a database to address questions like that. The database includes 17 of the largest 20 commercial payers and includes thousands of specialty drug coverage decisions. In our paper published in Health Affairs last summer, we found that of hundreds of specialty drugs, only 16% were covered in the same way by the 17 commercial payers in our sample, meaning that 84% of those specialty drugs, coverage differed, meaning that one payer added restrictions to coverage while another payer did not. So, for instance, that could be that one payer added a step added to the coverage decision while another payer did not, or it could simply be that one payer added some kind of patient subgroup restriction, meaning that only patients who met certain clinical criteria could get access to the drug while other payers did not.

How does this variability impact patient outcomes?

I think this variability is very important and maybe most importantly, it does impact patients’ access. It means that a patient’s access differs depending on their insurance company. So, patients with similar clinical characteristics have differing access simply because they’re covered by different insurance companies. Also, I think importantly for patients who are switching between health plans, this could affect their access to a drug on which they’re currently stable on their initial health plan. I think it’s very important to quantify and really grasp that. The last thing would be for physicians and maybe other prescribing providers in that those providers will be tailoring their treatment decision not only to the patient’s clinical presentation or clinical characteristics but also to the patient’s insurance coverage, and therefore, this variation is very important to quantify and there’s a lot of work to be done to understand why this exists.