Institute for Clinical & Economic Review, Boston, MA 02109, USA.
Office of Health Economics, London, UK.
J Comp Eff Res. 2021 May;10(7):537-547. doi: 10.2217/cer-2021-0027. Epub 2021 Mar 1.
At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy and required switching. In each of these domains we present 'ethical goals for access' followed by a series of 'fair design criteria' that can be used by stakeholders to drive more transparent and accountable drug coverage.
所有医疗保险计划的核心都存在伦理上的紧张关系，一方面是最大化患者和临床医生为个体定制医疗服务的自由，另一方面是需要使医疗保健负担得起。在药品福利设计和覆盖政策方面，这种紧张关系的争论最为激烈。本文重点关注三个最具争议的领域，即如何判断药物覆盖是否合适：共付额规定、临床资格标准以及经济阶梯疗法和必需的转换。在这些领域中的每一个领域，我们都提出了“准入的伦理目标”，然后提出了一系列“公平设计标准”，利益相关者可以使用这些标准来推动更透明和负责任的药物覆盖。
