Making high-value specialty drugs affordable will save lives and reduce healthcare costs

Millions of Americans intent on getting the best value for their healthcare dollars are scrambling to sign up for the new exchanges under the Affordable Care Act. Yet even as they do, a critical piece of the healthcare equation – affordable access to specialty drugs – still needs changing.

The non-partisan Congressional Budget Office recently brought the relationship between the costs and benefits of medicines into sharp focus when in a November 2012 report it found that spending on prescription medications actually saves costs in other areas of healthcare spending.

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That’s because without taking the right medication, the patient’s condition will likely worsen, the treatment will become even more expensive, and the outcome less certain. It is well established that the higher the co-pay, the less likely the prescription will be filled. 

By contrast, the CBO found that patients who take the medications they are prescribed actually save healthcare resources. These patients require fewer physician visits, use fewer emergency medical services, and have a better quality of life. The CBO concluded that the increased cost of providing more affordable prescription benefits is partially offset by significant savings in other healthcare spending.

The CBO findings invite the question of how we manage the costs of specialty tier medications. Among these advance medicines are new cancer drugs specially formulated for patients with specific genetic markers; individualized medications based on diagnostic testing; and “biologics,” or medicines created through biologic processes, rather than chemically synthesized like most pharmaceuticals. For a small sliver of the population, these treatments can literally be life savers.

While relatively few patients need these very high value medications, these therapies require extensive investment in research, testing, and manufacturing an thus carry a high cost per patient when compared to conventional pharmaceuticals.

Unfortunately, that often means co-pays for these specialty tier therapies under today’s insurance plans are so high that many patients can’t afford them. Some are confronted with thousands of dollars a year in out-of-pocket costs. Even though the insurance company says they ‘cover’ a medication in their formulary, it can become effectively unavailable to the patient because they simply cannot afford the out-of-pocket co-pay. 

This is the piece of the healthcare equation that still needs changing. A bi-partisan group of lawmakers in Washington is looking to do just that. This summer, they took action on the CBO findings and proposed legislation, the Part D Beneficiary Appeals Fairness Act, that would ensure that Medicare beneficiaries can afford the medications they are prescribed by allowing them to request lower co-pays.  

Specialty-tier therapies are expensive because so relatively few people suffer from the diseases these drugs are designed to treat. So the small pool of patients means a higher cost per patient, but it also means that relatively few people need help meeting their outsized co-pays.

By comparison, there is a huge pool of patients using only the "common" medications in the insurance carriers' lower tiers. Slight increases in co-pays for the many using lower-tier medications would ease the financial strain for the very few whose uncommon illnesses or chronic conditions require high-cost specialty tier medications.

I recently paid $5 for a generic prescription. I would have been happy to pay an additional dollar or two on my co-pay if it meant a more affordable co-pay if my parents or one of my family members were diagnosed with a cancer that needed treatment with a specialty tier drug.

When it comes to a choice between the cost of prescriptions and the cost of letting them go unfilled, it is clear which is higher. The cost of prescriptions – especially when taken as prescribed – is far less.

And the cost – both financial and ethical – of allowing a single person to be priced out of treatment altogether is far more than we can afford.

Charles is chairman of the Alliance for Patient Access and a practicing neurologist.