For a number of years, our clients have asked DRG to analyze benefit plan designs to determine year-over-year patient responsibility for therapy, with the goal of understanding the extent to which payer restrictiveness precludes meaningful access to certain products. DRG recently completed a detailed study of 1,000 of the nation’s largest Commercial and Health Insurance Exchange benefit plan designs to determine the wide spectrum of patient out-of-pocket costs for therapies, and how they’ve changed from 2015 to 2016. Here’s what we learned, in part:

  • In our sample, co-payments for visits to Primary care physicians within network increased by 43%
  • 14% of plans increased their co-pays for Emergency room (ER) visits by more than 100% in 2016
  • 50% of plans had a $5000 or higher Out-of-Pocket Maximum
  • 10% of plans have an Out-of-Pocket Maximum set at $6850 for 2016, of which 55% are PPOs
  • 15% of the plans offered first dollar coverage (zero dollar deductible)
  • Annual Out-of-Pocket Maximum increased by 19% in the premium plans in our sample

We believe in particular regions (Southeast and Southwest) this incremental out-of-pocket cost is impacting patient care and patients are seeking less care.  For example, more than 10% of PPO plans have increased their Out-of-Pocket Maximum in 2016; one of the California Commercial plans increased its Out-of-Pocket Maximum by almost 33%, making it difficult for subscribers to gain access to.

This study is part of an annual, syndicated Out-of-Pocket Analysis performed by DRG, which, along with our Out-of-Pocket Tool can be used to inform the out-of-pocket contributions patients will pay within a given state, payer, and benefit design. DRG’s Out-of-Pocket resources are designed to support market access tactics and planning, including:

  • Market Access team engagement with payers
  • Planning for the impact of complex benefit designs, including out-of-pocket payments where there is a combination of deductible, copayment, and coinsurance for care adjudicated under the medical and/or pharmacy benefit
  • Planning for Patient Assistance Program funding and foundation support
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And for more information, please contact any of the following:

Dan Jacob, Vice President, Innovation,

Kathy Bellitti, PharmD, Vice President,

Bhaskar Kumar, Director, Innovation,

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