Question

What are three criteria used by payers in the US to determine if a drug can be covered under their plans?

Answer 1

                        Affordability of healthcare of people depends on the health insurance owned by them. The US system of healthcare focus on the private investments in the healthcare sector more than the public spending. Thus the healthcare system in US has more of a managed care system wherein the payers will be provided with treatment as they requires and the drug cost will be deducted from the insurance plans linked o them. Thus the payer is given the opportunity to decide the level of drug delivery and care they need in accordance with the plan they have adopted. As the cost of healthcare has risen in the recent decade, the insurance policy design has also seen a considerable change. Now, the premiums have been decreased so as to increase the access to more people thereby to achieve benefit in the cost analysis. But the out of pocket expenditures of the payers are on the increase which have forced them to identify ways to find a more efficient way of selecting a drug.

                                    The following judgements are being decided upon by the payers before fixing a particular plan that they adopt for healthcare benefits.

· Gathering information on potential clinical outcomes

· Comparable effectiveness of alternative treatments

· Analysing out-of pocket expenditure for each drug

                                        Thus, based on the analysis of the above three mechanisms, the payer can take decision as to whether they should receive a particular strategy under the plan considered.