Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Dig Dis Sci. 2021 Dec;66(12):4140-4148. doi: 10.1007/s10620-020-06806-1. Epub 2021 Jan 12.
Prescription drug costs exert profound effects on commercial insurance coverage and access to effective therapy.
We aimed to assess threshold pricing to achieve budget neutrality of FDA-approved drugs treating irritable bowel syndrome from an insurance perspective, based on cost-savings resulting in decreased healthcare utilization through effective disease management.
We constructed a decision-analytic model from an insurance perspective to assess the budget impact of IBS prescription drugs under usual insurance coverage levels in practice: (1) unrestricted drug access or (2) step therapy in a primary care population of middle-age, care-seeking IBS patients. Budget-neutral drug prices were then calculated which resulted in $0 budget impact to insurers with a short-term, one-year time horizon.
If used according to FDA labeling, IBS-D drugs cost between $4778 and $16,844 per year and IBS-C drugs cost between $4319 and $4955 per year. These drug costs often exceed insurance expenditures of $6999 for IBS-D and $3929 for IBS-C if left untreated. Therefore, for drugs to have $0 budget impact to insurers, their prices would need to be discounted 36.7-74.2% for IBS-D drugs and 59.3-82.5% for IBS-C. IBS drugs are already priced to support step therapy "failing one of several common, inexpensive IBS treatments with a responder rate > 30-40%," reflecting the subpopulation with more severe disease and greater healthcare costs.
Broader prescription drug coverage for patients failing common, inexpensive IBS treatments to which at least 30-40% of patients would typically respond appears warranted to enable gastroenterologists to offer personalized approaches targeting specific mechanisms of this heterogeneous disease.
处方药成本对商业保险覆盖范围和获得有效治疗的机会产生深远影响。
我们旨在从保险角度评估门槛定价，以实现美国食品和药物管理局 (FDA) 批准的治疗肠易激综合征药物的预算平衡，这是基于通过有效的疾病管理减少医疗保健利用而节省的成本。
我们从保险角度构建了一个决策分析模型，以评估在实践中通常的保险覆盖水平下肠易激综合征处方药的预算影响：(1) 不受限制的药物获取或 (2) 在寻求治疗的中年初级保健人群中进行阶梯治疗。然后计算出导致保险公司在短期一年时间范围内没有预算影响的中性药物价格。
如果按照 FDA 标签使用，IBS-D 药物每年的费用为 4778 美元至 16844 美元，IBS-C 药物每年的费用为 4319 美元至 4955 美元。如果不治疗，这些药物成本通常超过 IBS-D 的保险公司支出 6999 美元和 IBS-C 的保险公司支出 3929 美元。因此，为了使保险公司的药物没有预算影响，它们的价格需要为 IBS-D 药物折扣 36.7-74.2%，为 IBS-C 药物折扣 59.3-82.5%。IBS 药物的定价已经支持阶梯治疗，即对有 30-40%以上应答率的几种常见、廉价的 IBS 治疗方法“失败”的患者进行治疗，这反映了疾病更严重和医疗费用更高的亚人群。
为了使胃肠病学家能够提供针对这种异质疾病特定机制的个性化方法，为常见、廉价的 IBS 治疗方法失败的患者提供更广泛的药物覆盖范围，这似乎是合理的，至少有 30-40%的患者通常会对此类治疗有反应。
