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'Tier 4' Drugs Raise Questions About Affordability

Insurers' plan for drugs such as biologic agents requires patients to dig deep at a tough time

WEDNESDAY, July 23 (HealthDay News) -- The emergence of a fourth tier of copayment for expensive drugs calls into question how Americans are going to handle the rising costs of health care, according to a perspective article in the July 24 issue of the New England Journal of Medicine.

Thomas H. Lee, M.D., of Partners Healthcare System in Boston, and Ezekiel J. Emanuel, M.D., Ph.D., of the National Institutes of Health in Bethesda, Md., write that insurers are increasingly requiring a fourth tier of patient payment for drugs such as biologics. Rather than paying $50, as they might for a tier 3 drug, patients may have to pay up to 33 percent of the cost of a drug -- a challenge for many Americans, particularly during illness.

Given that most people will need an expensive intervention at some point, shifting these costs to the sick is an issue of concern to society at large, the authors note. One solution could be for insurance to cover only interventions that actually work, and using interventions with indeterminate effectiveness only in cases where they're likely to help, they write.

In addition, "Providers could agree that considering costs in treatment decisions does not violate the Hippocratic oath and that improved efficiency is a core value of medicine today. We could strive to ensure that everyone receives effective treatment, rather than spending more and more on ineffective interventions that end up not just wasting money, but also breeding resentment and conflict over who can afford to live and who cannot," the authors conclude.

Emanuel is an unpaid member of the Humana Europe board.

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