April 11, 2016 - Curant COO, Marc O'Connor, in Specialty Pharmacy Times - FACT: THE AFFORDABLE CARE ACT (ACA) succeeded in increasing the number of insured Americans.
According to the National Center for Health Statistics, there were 16 million fewer uninsured Americans as of September 2015, than in 2013. More specifically, the percentage of uninsured adults aged 18-64 decreased from 22% in 2010 to 13% in the first 9 months of 2015.1
One unintended consequence of the ACA, however, is the creation of a glut of patients awaiting authorization for the exact therapies, or actual cures, for which payers have long clamored.
What is even worse, some patients who stand to benefit most from specialty medications have their prescriptions authorized and filled, only to learn that refills of Harvoni, for example, run into a monthly prior authorization barrier from their pharmacy benefit manager or payer.
At risk of failing to adhere to the costly but valuable regimen due to this barrier, the patient, their payer, and their physician increase the collective risk of resistance to the therapy. We are learning that new curative therapies cannot be treated the same way as legacy and low-cost medication therapies.
Rising Number of Insured + Rising Numbers of Specialty Drugs and Prices = Roadblocks to Value
According to a recent report from The Pew Charitable Trusts, less than 1% of all prescriptions were written for specialty drugs in 2014, yet they accounted for approximately 32% of total drug expenditures.
“Utilization rose by 5.8% in 2014 because of increased use of existing drugs and the introduction of new pharmaceuticals. In 1990, only 10 specialty drugs were on the market,” the authors wrote. “Currently, approximately 300 such drugs are on the market, 19 of which became available in 2014 alone. And nearly 700 specialty drugs are under development.”2
The meteoric increase in the number and cost of specialty medications, added to the growing population of insured Americans, has created a one-two punch in the guts for patients and providers. While the average time per patient interaction for clinicians continues to shrink, providers are now mired in a worsening administrative bog of prior authorization forms.
At the same time, patients often forego therapy–putting them at greater risk of becoming acute or requiring other, more costly care–due to slow prior authorization processes or out-of-pocket costs, including medication co-payments, they simply cannot afford. It’s a situation akin to classic traffic congestion.
Increasing the volume of vehicles to a constant volume of highway capacity breeds gridlock. Adding new lanes, an immensely expensive proposition, is only a short-term solution. What is needed is taking vehicles off of the roads by giving users effective alternatives.
In the same way bike paths and mass transportation options move people efficiently through a city, pharmaceutical industry alignment should improve access, adherence, and outcomes for all concerned.
To read Marc's full article, visit Specialty Pharmacy Times.
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