by Brian Kennedy, Executive Director, Alliance for Patient Access
A physician tells a story in the Alliance for Patient Access’ oncology working group white paper about attending the funeral of one of his cancer patients. The patient hadn’t been responding to treatment, and the physician couldn’t understand why. At the funeral, this physician learned the truth. At the expense of his own health, the patient had stopped taking his high-priced medication because he couldn’t bear to bankrupt his family.
In a white paper from AfPA’s respiratory working group released earlier this month, another physician tells a story. He describes a conversation with a patient, an elderly lady with limited resources and a difficult dilemma. She asks him, “What should I do? Do I buy food for my grandchildren or medication for myself?” For situations like these, the physician explains, “I have no words.”
The issues of high medication prices and unmanageable health plan cost-sharing are everywhere. And for more than a year, the policy-minded health care providers who make up the Alliance for Patient Access have asked: What do we do?
Today, AfPA is releasing a policy proposal entitled “Informed Drug Pricing.” Shifting the discussion beyond economics, and back to patients, AfPA is offering a powerful suggestion to both the pharmaceutical companies that develop today’s innovative advanced medicines and the health plans who foot the bill:
To encourage pricing decisions and coverage policies that ensure patient access, you must open deliberations on these questions to those who are directly impacted – health care providers and patient advocates.
As the AfPA policy proposal explains, physicians have an unmatched perspective on issues related to patient access. They understand disease states, symptoms, and the effect of co-morbidities. They talk to patients and have insight into their ability – or their struggle – to pay for medication. They understand the therapeutic landscape: what other medications exist to treat a certain condition, the side effects, and the cost. Where else could pharmaceutical companies and health plans find this breadth of knowledge in a single person?
Patient advocates likewise bring a unique and powerful perspective. Many patient advocates are or were patients themselves, so they have first-hand knowledge. But they also offer a broad perspective – they engage with physicians, insurers, patients and other members of the health care system. It’s no wonder that more groups are calling upon patient advocates to advise government agencies, international health organizations, policy groups and more.
AfPA’s proposal explains that high drug prices create patient access barriers in two ways. The first way is obvious—prices rise, causing patients’ out-of-pocket expenses to also rise. Patients who can’t afford the co-pays and co-insurance are priced out of access to their medications.
The second way may be less obvious but equally important. Health plans use high drug prices to justify techniques that limit patient access – prior authorizations, fail first policies, specialty tiers and non-medical switching, where a stable patient gets directed to a less costly alternative to minimize health plan costs. Rising concern about drug prices can create the pretext for health plans to impose these tactics more and more. As a result, more and more patients struggle to access the medications their doctors prescribe.
What the Alliance for Patient Access would like to see is pharmaceutical manufacturers and health plans using physician and patient advocates’ insight to address both of these barriers.
Pharmaceutical manufacturers pricing a new drug or considering increasing the price of an existing medicine should seek out the insights of physicians and advocates representing patients to gauge the impact of the price on patient access and treatment. Similarly, health plans considering placing a drug on a specialty tier with high cost-sharing requirements should consider what health care providers and patient advocates have to say about the impact on patient access.
If we want decisions that help patients get the medications they need, let’s start by expanding the conversation to include those most affected.