Health Coverage Transparency: Through the cancer lens Hilary Scheinder
The Patient Experience: Through the cancer lens Before a cancer diagnosis… The Shopper The Patient Low premium meant high cost sharing � What premium can I afford? Didn’t know the closest oncology � Is my PCP in network? provider is 45 minutes away I have to pay a 30% coinsurance for � Are my current meds covered? my chemotherapy treatment � Could I afford cost of Urgent Can’t pay my $3,000 deductible for Care/ER Visit? surgery….
The Patient Experience: Through the Cancer Lens Premium Fam 4, Age Med Ded Drug Ded OOP Max In/out Ptnt Fac. Indiv.l Age 50 30 Med Ded Drug Ded Fam Fam OOP Max Fam Specialist (post ded.) Specialty Drugs $231.75 $525.54 $2,750.00 $0.00 $8,250.00 $0.00 $6,350.00 $12,700.00 10% after deductible 10% 10% post ded 5 visit@ $35, 0% after $225.83 $512.10 ded $3,600.00 $0.00 $7,200.00 $0.00 $3,600.00 $7,200.00 0% 0% post ded 5 visit@ $35, 0% after $215.72 $489.18 ded $4,400.00 $0.00 $8,800.00 $0.00 $4,400.00 $8,800.00 0% 0% post ded $228.07 $452.06 $2,750.00 $0.00 $5,500.00 $0.00 $4,000.00 $8,000.00 20% after deductible 20% 20% post ded $228.07 $452.06 $2,750.00 $0.00 $5,500.00 $0.00 $4,000.00 $8,000.00 20% after deductible 20% 20% post ded $232.05 $459.94 $2,000.00 $0.00 $4,000.00 $0.00 $6,350.00 $12,700.00 20% after deductible 20% 20% post ded $235.42 $466.62 $1,500.00 $500.00 $3,000.00 $500.00 $6,350.00 $12,700.00 $65 20% 20% post ded $237.53 $470.79 $2,650.00 $0.00 $5,300.00 $0.00 $6,350.00 $12,700.00 $60 30% 25% $237.53 $470.79 $2,650.00 $0.00 $5,300.00 $0.00 $6,350.00 $12,700.00 $60 30% 25% $237.79 $471.30 $2,000.00 $500.00 $4,000.00 $500.00 $6,350.00 $12,700.00 $50 20% 20% post ded $239.12 $473.96 $2,000.00 $0.00 $4,000.00 $0.00 $6,350.00 $12,700.00 20% after deductible 20% 20% post ded $242.60 $480.84 $1,500.00 $500.00 $3,000.00 $500.00 $6,350.00 $12,700.00 $65 20% 20% post ded $245.03 $485.68 $2,000.00 $500.00 $4,000.00 $500.00 $6,350.00 $12,700.00 $50 20% 20% post ded $215.09 $487.74 $3,500.00 $0.00 $7,000.00 $0.00 $3,500.00 $7,000.00 0% after deductible 0% 0% post ded
The Patient Experience: Through the Cancer Lens Before a cancer diagnosis… • Plan transparency might be less of an issue when the patient has not yet been diagnosed • Healthy people tend to choose lower premium plans with higher cost sharing • Affordability and Access could be more prevalent for those who choose a plan before diagnosis • States are taking some steps to ensure provider network adequacy and drug affordability
The Patient Experience: Through the Cancer Lens The Shopper The Patient After a cancer diagnosis… Need to be sure I can afford I paid a higher premium to avoid up • my premium AND deductible front deductible for chemo I could only access a provider list AFTER I Are all of my oncologists in- • bought the plan.. My oncologist is network? covered as a “tier 2” provider. Are my drugs on the formulary Couldn’t find my IV drug on the formulary • and can I afford them? and my oral drug had a 20% coinsurance, which turned out to be $2,000 per month! What is my cost sharing for CT • 30% coinsurance, who knows what my scans, PET scans, MRI’s? bill will be????
The Patient Experience: Through the Cancer Lens After a cancer diagnosis… • When a cancer patient is shopping for health insurance, they are more likely to know what they need • More likely to understand how provider networks, utilization management and cost sharing works • Plan transparency and an ability to easily compare options is most important • Some states taking action to require greater transparency standards
The Patient Experience: Through the Cancer Lens • March 2014 ACS CAN Study: Cancer Drug March 2014 ACS CAN Study: Cancer Drug March 2014 ACS CAN Study: Cancer Drug March 2014 ACS CAN Study: Cancer Drug Coverage in Health Insurance Marketplaces Coverage in Health Insurance Marketplaces Coverage in Health Insurance Marketplaces Coverage in Health Insurance Marketplaces • Formularies and search tools varied widely – Some list only commonly prescribed drugs – Some do not indicate tier structure – Most have disclaimers • Several plans only provided a general homepage link • Nearly impossible to find out which IV drugs are covered in the medical benefit. • Difficult to match cost-sharing information to formularies.
Thank You! Thank You! Thank You! Thank You!
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