Appropriate benefit design—copay structures and tiers—is an important factor in providing members and patients with access
to treatment that is affordable. Meanwhile, cost sharing with consumers continues to increase because of pressures on maintaining
competitive premium costs and the lack of innovative means to manage utilization, say experts.
HMO pharmacy copay comparison
"As costs are shifted more to the member, access and affordability decrease for some members," says Robert Taketomo, president
and CEO at Ventegra. "This could lead to non-compliance with treatment, which results in more expensive care in the future."
Historically, benefit designs have not been well integrated with utilization or disease management, he says. "That's because
health plans typically have managed these in separate silos [e.g., product development/marketing/finance for benefit designs
and medical management/pharmacy for utilization]," he says. "A proactive, integrated approach to ensuring that members have
the right information and affordable access to prescribed therapy would be a good objective for future programs. Benefit design
must be integrated with management systems to ensure appropriate monitoring of patient care, with intervention occurring in
a patient-and provider-friendly manner. Most importantly, patients, providers and employers would be engaged in the design
of these programs to ensure that their needs are addressed."
SLIGHT INCREASES
The chart indicates no change in copayment tiers for the two-and three-tier plans. "Most of the changes—in growth and increase
in differential between the tiers—were in the fourth-and fifth-tier plans," Taketomo says. "This is consistent with a desire
by the health plans to shift members to the four-tier and five-tier plans. The danger is that a flat coinsurance—such as 25%—could
provide a significant disincentive for a patient to receive care.
"For example, a member receiving a $1,200 prescription would have to pay $300 for each refill. An ideal injectable benefit
design would allow appropriate access of injectable drugs in an affordable manner," Taketomo says.
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