美国商业健康计划覆盖范围 肺动脉高血压治疗中的动态
Julia A Rucker1, Molly T Beinfeld1, Daniel E Enright1
1The Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA.
随着时间的推移,肺动脉高血压 (PAH) 治疗的健康计划覆盖范围变得越来越严格. 这些覆盖限制,包括步骤治疗,在计划之间存在很大差异,可能会阻碍患者获得必要的PAH疗法.
科学领域:
- 卫生经济学 卫生经济学
- 制药政策 制药政策
- 罕见疾病管理 罕见疾病管理
背景情况:
- 医疗保险计划的覆盖面对患者获得罕见,慢性疾病,如肺动脉高血压 (PAH) 的专用药物有重大影响.
- 治疗PAH的指导方针建议使用多种药物类别的组合疗法,包括固酶5抑制剂 (PDE5is),可溶性酸环酸激酶刺激剂 (sGC刺激剂),内啡素受体对抗剂 (ERA) 和前环素通路代理剂 (PPA).
研究的目的:
- 评估商业健康计划对PAH治疗的覆盖范围的变化和演变.
- 分析覆盖政策更新的频率和健康计划使用的证据类型.
主要方法:
- 利用塔夫斯医疗中心专业药物证据和覆盖数据库,分析了17个美国大型商业健康计划的公开覆盖政策.
- 识别和分类计划规定的覆盖范围限制 (例如,步骤治疗,临床标准,处方者要求) 超出FDA批准的适应症.
主要成果:
- 2017年8月至2022年8月期间,PAH治疗的覆盖限制大幅增加,至少包含一个限制的保单比例从38%上升到73%.
- 步骤治疗方案和处方者限制变得越来越普遍,影响了所有主要的PAH治疗类别,特别是那些具有通用可用性的类别.
- 医疗计划每年更新约58%的政策,经常引用2019年CHEST临床指南和随机对照试验.
结论:
- 商业医疗计划越来越多地实施了对肺动脉高血压治疗的保险限制.
- 在各个健康计划中观察到的PAH治疗覆盖范围的变化和越来越严格的限制可能会对患者的访问和治疗坚持造成障碍.
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