药物覆盖政策和临床指南调整:大多数覆盖决策包括额外的限制
Julia A Rucker1, Molly T Beinfeld2, Katherine A Clifford3
1Julia A. Rucker, Tufts Medical Center, Boston, Massachusetts.
Health affairs (Project Hope)
|July 7, 2025
概括
卫生计划经常使用专用药物的利用管理标准,但其标准与临床实践指南不太一致. 这影响了患者获得必要药物的机会.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 制药政策 制药政策
- 临床实践指南 临床实践指南
背景情况:
- 使用管理 (UM) 标准显著影响患者获得特殊药物的机会.
- 卫生计划用于创建UM标准的方法尚未完全理解.
- 了解临床指南与UM标准之间的对齐对于患者获取至关重要.
研究的目的:
- 检查临床实践指南与专用药物健康计划规定的利用管理标准之间的一致性.
- 评估健康计划在制定覆盖政策时如何一致遵守指导方针建议.
主要方法:
- 从美国临床实践指南 (不包括瘤学和生物仿制药) 中审查了389种药物指示对,使用塔夫斯医学特种药物证据和覆盖数据库 (2023年12月).
- 根据他们是否推UM,考虑与FDA标签信息 (治疗线,临床要求) 保持一致的指南进行分类.
- 分析了来自18个大型商业健康计划的5699项保险政策.
主要成果:
- 大多数健康计划 (61%) 对药物保险决策施加了UM标准.
- 当指导方针推UM时,67%的计划覆盖决策一致.
- 当指导方针没有推UM时,只有37%的计划决策是一致的,这表明整体调整很弱.
结论:
- 在健康计划UM标准和临床实践指南建议之间存在显著的不一致性.
- 当UM被推时,医疗计划更有可能与指导方针保持一致,但整体一致性仍然很弱.
- 这种错位可能会给患者带来障碍,使他们无法获得适当的特殊药物治疗.
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