How will we manage?

V. Carroll
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Generic drugs were nearly always less expensive for the individual consumer because competition from generic drugs ‘‘is the most effective way of slowing the spiraling cost of pharmaceuticals’’ (AARP’s Brief Amicus Curiae, 2010). Drug copayments were traditionally divided into three tiers; copayment costs were less for Tier I drugs and more expensive for Tier 3 drugs. The incentive to choose a generic form of a drug, when available, was lower cost. Now, however, the growing number of biologic drugs available to treat cancer, immune disorders, and a variety of chronic illnessesVincluding multiple sclerosis (MS)Vhas caused some insurers to create a fourth copayment tier. This fourth tier has been introduced for drugs that are particularly expensive, and patients are being asked to pay a significantly larger ‘‘share’’ of the cost, often as much as 20%Y30% of the fixed cost of these agents. Included in the Tier 4 group are drugs like the tumor necrosis factor blocker etanercept, trastuzumab (Herceptin), the interferons, and glatiramer acetate (Copaxane). Patients who require Tier 4 drugs are likely to incur ‘‘Iout-of-pocket (OOP) expenses which far exceed what their budgets can bear’’ (Lee & Emmanuel, 2008, p. 333). Newer oral biologic agents will have no generic equivalent, will be patent protected for many years to come, and will certainly be classified as Tier 4 agents in terms of copayments. What does this mean for our patients? The evidence tells us that as OOP costs rise, adherence to therapy falls. A study reported in the Journal of Managed Care Pharmacy (Gleason et al., 2009) indicated that OOP expenses greater than $200 for MS medication were associated with increased prescription abandonment; in other words, patients simply stopped having their prescriptions filled. Their analysis of administrative claims over a 2-year period found that individuals were 8% more likely to stop therapy for every $10 increase in OOP drug costs. More than 400,000 individuals in the United States have been diagnosed with MS, and an additional 10,000+ new cases are identified annually. Adherence to current biologic treatment regimens is complicated by injection anxiety, adverse reactions to the injections, real and/or perceived lack of efficacy, and cost. Discontinuation or abandonment rates are between 9% and 20% in the first 6 months of treatment (Lipsy, 2010). As newer, oral biologics enter the treatment arena and market, patients will be able to choose a drug that does not require injectionVa huge positive in maintaining adherence to treatment. The downside is that these drugs will have no generic (cheaper) form for many years and will come onto the market with Tier 4 copayments. How do we, as neuroscience nurses, play a role in this unfolding economic scenario? We can advocate for better, more cost-effective access to treatment. We can campaign for changes in the Food and Drug Administration process for approving generic drug formulations. We can lobby for modifications in the structure of tiered copayment. We can teach patients and families to care for themselves in ways that promote optimal outcomes. We can become actively involved in the larger discussion of how we, as healthcare providers and individual consumers, will deal with rising healthcare costs in general. To paraphrase the Golden Rule, we should ‘‘manage others that way we would like to be managed.’’","PeriodicalId":94240,"journal":{"name":"The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2011-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"2","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1097/jnn.0b013e318207b65a","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 2

Abstract

Managed care has been an inescapable part of healthcare for decades. We encounter it collectively as healthcare providers and individually as healthcare consumers. The ways in which managed care plans pay for services, as well as the services for which they pay, underpin the provision of almost all healthcare in the United States. Managed care options and reimbursement are critical points in the discussion of healthcare reform. Tiered copayments for prescription drugs have long been a part of insurers’ cost containment strategies, with patients paying fixed amounts from their own funds when a prescription is filled; the dollar amounts vary depending on the cost of a particular drug and whether a less expensiveVgenericValternative exists. Generic drugs were nearly always less expensive for the individual consumer because competition from generic drugs ‘‘is the most effective way of slowing the spiraling cost of pharmaceuticals’’ (AARP’s Brief Amicus Curiae, 2010). Drug copayments were traditionally divided into three tiers; copayment costs were less for Tier I drugs and more expensive for Tier 3 drugs. The incentive to choose a generic form of a drug, when available, was lower cost. Now, however, the growing number of biologic drugs available to treat cancer, immune disorders, and a variety of chronic illnessesVincluding multiple sclerosis (MS)Vhas caused some insurers to create a fourth copayment tier. This fourth tier has been introduced for drugs that are particularly expensive, and patients are being asked to pay a significantly larger ‘‘share’’ of the cost, often as much as 20%Y30% of the fixed cost of these agents. Included in the Tier 4 group are drugs like the tumor necrosis factor blocker etanercept, trastuzumab (Herceptin), the interferons, and glatiramer acetate (Copaxane). Patients who require Tier 4 drugs are likely to incur ‘‘Iout-of-pocket (OOP) expenses which far exceed what their budgets can bear’’ (Lee & Emmanuel, 2008, p. 333). Newer oral biologic agents will have no generic equivalent, will be patent protected for many years to come, and will certainly be classified as Tier 4 agents in terms of copayments. What does this mean for our patients? The evidence tells us that as OOP costs rise, adherence to therapy falls. A study reported in the Journal of Managed Care Pharmacy (Gleason et al., 2009) indicated that OOP expenses greater than $200 for MS medication were associated with increased prescription abandonment; in other words, patients simply stopped having their prescriptions filled. Their analysis of administrative claims over a 2-year period found that individuals were 8% more likely to stop therapy for every $10 increase in OOP drug costs. More than 400,000 individuals in the United States have been diagnosed with MS, and an additional 10,000+ new cases are identified annually. Adherence to current biologic treatment regimens is complicated by injection anxiety, adverse reactions to the injections, real and/or perceived lack of efficacy, and cost. Discontinuation or abandonment rates are between 9% and 20% in the first 6 months of treatment (Lipsy, 2010). As newer, oral biologics enter the treatment arena and market, patients will be able to choose a drug that does not require injectionVa huge positive in maintaining adherence to treatment. The downside is that these drugs will have no generic (cheaper) form for many years and will come onto the market with Tier 4 copayments. How do we, as neuroscience nurses, play a role in this unfolding economic scenario? We can advocate for better, more cost-effective access to treatment. We can campaign for changes in the Food and Drug Administration process for approving generic drug formulations. We can lobby for modifications in the structure of tiered copayment. We can teach patients and families to care for themselves in ways that promote optimal outcomes. We can become actively involved in the larger discussion of how we, as healthcare providers and individual consumers, will deal with rising healthcare costs in general. To paraphrase the Golden Rule, we should ‘‘manage others that way we would like to be managed.’’
我们将如何管理?
几十年来,管理式医疗一直是医疗保健不可避免的一部分。我们作为医疗保健提供者和个人作为医疗保健消费者共同遇到它。管理式医疗计划支付服务费用的方式,以及他们支付的服务,是美国几乎所有医疗保健服务的基础。管理医疗方案和报销是讨论医疗改革的关键点。长期以来,处方药的分层共付一直是保险公司成本控制策略的一部分,当处方被填满时,患者从自己的资金中支付固定金额;金额取决于特定药物的成本以及是否存在更便宜的非专利替代品。对于个人消费者来说,仿制药几乎总是更便宜,因为来自仿制药的竞争“是减缓药品成本螺旋式上升的最有效方式”(AARP的法庭之友简报,2010)。药品共同支付传统上分为三个层次;一级药物的共付费用较低,三级药物的共付费用较高。当有仿制药时,选择仿制药的动机是更低的成本。然而现在,用于治疗癌症、免疫系统疾病和多种慢性疾病(包括多发性硬化症(MS))的生物药物越来越多,这促使一些保险公司创建了第四个共同支付级别。第四层是针对那些特别昂贵的药物,病人被要求支付更大的费用“份额”,通常高达这些药物固定成本的20%至30%。第4级包括肿瘤坏死因子阻滞剂依那西普、曲妥珠单抗(赫赛汀)、干扰素和醋酸格拉替默(Copaxane)等药物。需要第4级药物的患者可能会产生“自费(OOP)费用,远远超过他们的预算可以承受”(Lee & Emmanuel, 2008, p. 333)。较新的口服生物制剂将没有仿制药,将在未来许多年受到专利保护,并且在共同支付方面肯定会被归类为第4级制剂。这对我们的病人意味着什么?证据告诉我们,随着OOP成本的上升,对治疗的依从性下降。《管理护理药学杂志》(Journal of Managed Care Pharmacy, Gleason et al., 2009)报道的一项研究表明,MS药物的OOP费用超过200美元与处方放弃增加有关;换句话说,病人只是停止了他们的处方。他们对两年时间内行政索赔的分析发现,面向对象的药物费用每增加10美元,个体停止治疗的可能性就增加8%。在美国,有超过40万人被诊断患有多发性硬化症,每年还有1万多例新病例被确诊。注射焦虑、注射不良反应、实际和/或感知的疗效不足以及成本,使当前生物治疗方案的依从性变得复杂。在治疗的前6个月,停药或放弃率在9%至20%之间(Lipsy, 2010)。随着较新的口服生物制剂进入治疗领域和市场,患者将能够选择一种不需要注射的药物,这对维持治疗的依从性具有巨大的积极作用。不利的一面是,这些药物将在许多年内没有通用(更便宜)的形式,并将以第4级共同支付进入市场。作为神经科学的护士,我们如何在这一正在展开的经济场景中发挥作用?我们可以倡导更好、更具成本效益的治疗。我们可以争取改变食品和药物管理局批准仿制药配方的程序。我们可以游说修改分层共付结构。我们可以教病人和家属以促进最佳结果的方式照顾自己。作为医疗保健提供者和个人消费者,我们可以积极参与更广泛的讨论,讨论我们将如何应对总体上不断上涨的医疗保健成本。套用黄金法则,我们应该“以我们希望被管理的方式来管理他人”。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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