Payers Are Partners in the Care of Patients

Even a casual observer would recognize that our nation’s health care system has undergone seismic changes over the past several years.

While all stakeholders – including physicians, hospitals and other providers, manufacturers of pharmaceutical and medical devices, insurers and, of course, patients – have been impacted by these changes, insurers or payers have been particularly affected by policies that have greatly expanded their base of customers, but also amended many longstanding market practices.

Making things even more complicated are rising costs for biopharmaceutical products, including many therapies patients with psoriasis and psoriatic arthritis rely on to keep their disease in check and to live fuller lives. Ultimately, a host of challenges, including insurance plans that place significant cost burdens for these therapies onto the shoulders of patients and that limit the network of providers—particularly specialists—covered by plans, are keeping individuals with psoriatic disease from accessing clinically necessary treatments.                                                                            

The National Psoriasis Foundation (NPF) has long recognized that payers are an important partner in the care of our community. We know their jobs are not easy, and we recognize the many demands they must navigate. At the same time, we want to explore ways NPF can work more closely with payers to have substantive dialogue on these issues and to ultimately help inform and shape coverage policies impacting our constituents. In January, we took a sizeable step toward achieving this goal.

Meeting brings together providers, patients and payers

On Jan. 29, NPF and the Board of International Dermatology Outcomes Measures (IDEOM), a nonprofit working to develop and validate outcomes measures, convened a day-long meeting including a half-dozen persons from the payer community along with leading psoriatic disease clinicians and researchers and patient representatives. Meeting participants included representatives from one of the three largest national health insurers and from regional plans, including a Blue Cross Blue Shield affiliate, an actuary and a former state Medicaid director.

Participants dug deep into a host of complex issues focused on better understanding what information payers need to shape their coverage polices.  

This diversity of payer perspectives, along with the presence of leading clinical experts in both psoriasis and psoriatic arthritis and powerful patient testimonials, made for a productive discussion. Ultimately, we heard from payers that therapies with higher costs do, understandably, receive more scrutiny and, in some cases, experience limits on access. As the health care system shifts to one focused around value, these pressures are anticipated to remain for the foreseeable future, particularly as payers are making decisions from a population health perspective.

We also heard from payers that they are very interested in understanding when and how any therapy provides benefits to the health of their members and that they are particularly interested in treatments that might reduce overall costs to the plan.

Payers offer input on NPF and IDEOM goals

Payer participants also provided valuable feedback to guide the actions of both NPF and IDEOM. They noted the disconnect between trial data and clinically meaningful outcomes data and made clear that they need to see standardized outcomes measures and evidence-based and up-to-date practice guidelines that influence clinical practice. The more precise such guidelines can be with regard to treatment and the more widely they are used, the more they can impact payer decisions.

The latter point is particularly important for clinicians as you go about incorporating the latest guidelines into your practice decisions. While it was not terribly surprising to hear that a lack of comparative effectiveness data is a barrier to payers, it was interesting to hear that a lack of agreement on the appropriate treatment target is too, particularly given products in the pipeline that could move this needle in a significant way. These data points aligned nicely with the work of NPF and IDEOM on both the outcomes measures and appropriate treatment targets.

Payers also spoke of the roles patient advocacy and quantifiable data play in shaping decisions, both issues in the strike zone for NPF, particularly with our new Patient Navigation Center. Through this center, NPF will directly serve a much larger group of patients each year and collect data on access to care and related challenges.

Laying the foundation for future work with payers

NPF will continue to work at both the federal and state levels on an array of access policy issues with plans to step up direct engagement with payers in the months ahead. While the meeting did not instantaneously solve the access challenges for our community, it provided a solid foundation upon which NPF and IDEOM can – and will – be building for the future. Reflecting back on this meeting, we confirmed NPF and IDEOM are taking the right steps to improve access to care for our community.

Collaborations among patients, providers and payers will improve access. This will not always be easy; continued movement toward paying for value and shifts from copays to coinsurance make patients more sensitive to these issues. In addition, the value shift is pushing more risk to the provider level. Nonetheless, if we can bring good evidence, clear guidelines and more data to payers, we can improve care.