The EACH/PIC Coalition submitted comments to the Washington PDAB urging the board to focus their affordability reviews on patient-reported hardships and examining the results of the Advisory Group reports published by the board.
The letter stated:
“As the board conducts its affordability reviews and considers potential policy solutions, we respectfully encourage it to allow the evidence gathered through its own process to guide the path forward. The experiences documented in the Advisory Group reports closely complement the findings from our recent Patient Experience Project: Patient-Reported Affordability & Unaffordability Survey 2.0 and reinforce an important conclusion: the affordability challenges patients experience are frequently driven by insurance coverage and benefit design, not directly by the price of an individual medication.”
“These findings closely complement the experiences documented by the board’s Advisory Group. Throughout the Enbrel report, respondents repeatedly identified prior authorization, step therapy, deductibles, coinsurance, formulary restrictions, and barriers to financial assistance as the reasons patients struggled to access or afford treatment. Collectively, these findings suggest that insurance benefit design frequently determines patient affordability far more than the price of a medication alone.”
“The board’s review process has generated valuable information about the challenges patients experience. We encourage the board to allow those findings to inform the policy solutions it ultimately pursues.”
“An Upper Payment Limit (UPL), however, does not directly reduce patient deductibles, coinsurance, or other out-of-pocket costs. Nor does it guarantee that any changes in reimbursement will translate into lower costs for patients.”
“At the same time, reimbursement limits may create incentives for insurers and pharmacy benefit managers to respond through additional utilization management, formulary changes, adverse tiering, or non-medical switching, the very barriers patients have consistently identified as contributing to unaffordability and disruptions in care. UPLs therefore risk worsening patient problems, while also failing to lower patient costs.”