Restricting Drug Access Not Aligned with Patient, Public Health


By John Thero

Healthcare’s reality drama of today often features drug pricing as a bogeyman in the overall cost of healthcare. The escalation in healthcare costs is far more complex. 

Multiple factors are at work in making healthcare costs uncomfortable both for patients and our nation. First, it’s undeniable that healthcare costs are impacted by lifestyle choices, such as too much fast food and too little exercise, and not enough focus on preventive care. We have a sick-care system – that waits to address issues when they become acute and the most expensive, rather than a healthcare system. As such, our society often underinvests in areas where we can reduce costs – like preventing and blunting chronic disease, including the deadliest one, cardiovascular disease.

A crucial driver in this underinvestment is a set of structural mechanism in our system that can hamper use of available preventative therapies. For instance, insurance companies often require patients to pay high out-of-pocket costs for newer, innovative medicines. These patient out-of-pocket costs have the effect of a disincentive, swaying people to not take new drugs, even though they may be better for their health. In addition, insurers often make older, generic products more readily accessible to physicians and patients, even when they are not as clinically useful or inexpensive. The downstream effects are missed opportunities to reduce chronic disease and higher overall healthcare costs, such as sicker patients, surgeries, hospital stays and rehabilitation.

For instance, cardiovascular disease is a catastrophe in plain sight; heart disease needs new, affordable, cost-effective medicines that prevent the number one killer in the United States. Reducing chronic disease has the potential to dramatically save healthcare costs by preventing the high costs associated with acute events such as heart attacks and strokes.

Many point out what’s wrong, but few offer solutions and examples to help fix this complex problem. We can reasonably price therapies which help reduce the effect of chronic diseases. Insurers can drive patient use of cost-effective, disease-reducing treatments by limiting patient cost-sharing. And flaws can be addressed in our pricing/rebate/incentive spiral – with an eye to the big picture of healthier patients at lower overall cost. 

We must rethink this. Lack of access for highly effective, proven preventative treatments runs contrary to the needed goals of reducing the burden of chronic disease, preventing costly sick-care and healthier people. Incentive structures should be aligned with patients and the public good by driving the use of more, proven preventative treatments.

Three things should virtually guarantee immediate, affordable insurance access for chronic disease patients. First, groundbreaking, rigorous clinical outcomes data should open the door. If major medical associations are quickly revising treatment guidelines to incorporate new breakthrough treatment data, insurance access must quickly follow to capitalize on it.

Second, guaranteed access should follow favorable independent determinations of cost-effectiveness for a medicine. Independent price watchdogs use very stringent analyses – often overly stringent – to assess whether branded drugs are cost-effective. Insurance assess should be accelerated when they find spending money on a drug is cost effective. This will lead to better preventative care and savings.

Third, responsible pricing by drug-makers should ensure sure-fire patient access to maximize a new chronic disease treatment’s impact in helping at-risk patients. Responsible pricing changes the dynamic; rapid insurance coverage will encourage responsible pricing. 

If a new medicine has all this – broad insurance access with minimal restrictions and few patient cost-sharing barriers is a slam dunk for patients and public health, right? Unfortunately, no. Various insurance companies resist covering new preventative treatment even when such therapies are FDA-approved, deemed cost-effective by third-party analysis and are recommended by medical societies. They argue any savings accrues to the patient and society – not them – in the future; but isn’t that the goal?

If society wants more health risk prevention and affordable priced therapies, patients, employers and physicians must make their views known to insurance companies. We must insist that insurance coverage make cost-effective products accessible to patients Otherwise, the cruel irony is that there is little incentive to develop and responsibly price drugs in the future.

John Thero is President and Chief Executive Officer of Amarin.