Study: Health Plans Don’t Seek Patient Input in Drug Coverage Decisions

Although health plans are increasing patients’ financial contribution for specialty medication, they are not seeking member input when developing drug coverage policies, according to a new study sponsored by the National Pharmaceutical Council and the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center in Boston.

The study, published in the Journal of Managed Care + Specialty Pharmacy, found that none of the plans they surveyed reported having a formal process for including member input into coverage decisions.

Lead author Brittany D'Cruz, M.P.H., of the Tufts center, and her co-authors indicated there was a lack of consensus about what role patients should play in drug policy decision-making. The health plans that were part of their study said involving patients would be labor intensive.

Including patients in this process is an important component of patient-centric health care said D'Cruz and her colleagues. "It may be that the fragmented nature of U.S. health care has been a contributing factor to the relative lack of patient involvement in decision-making,” investigators wrote.

Investigators reviewed health plans’ policy development processes and reviewed a data set of private health plan coverage decisions for specialty drugs. They conducted a survey with 21 respondents and conducted interviews with five plan leaders.

Almost half of the survey respondents reported having never engaged with members when developing coverage policies. Among respondents who had engaged with patients or members, most reported doing so only rarely. Those who were interviewed by investigators reported receiving patient and member input from satisfaction surveys or Internet-based surveys. Interviewees all said that patient insight regarding their experiences living with a disease, and the barriers patients face, is valuable.

“U.S. commercial health plans compare unfavorably to their counterparts elsewhere,” investigators wrote. “Health technology assessment agencies based in various countries, including Australia, Canada, Germany, and the United Kingdom encourage submissions from patient groups and consortiums.”