Health Coverage Transparency: Through the cancer lens Hilary - - PowerPoint PPT Presentation

Health Coverage Transparency:

Through the cancer lens Hilary Scheinder

The Patient Experience: Through the cancer lens

The Patient The Shopper

What premium can I afford? Is my PCP in network? Are my current meds covered? Could I afford cost of Urgent Care/ER Visit?

Before a cancer diagnosis…

Low premium meant high cost sharing Didn’t know the closest oncology provider is 45 minutes away I have to pay a 30% coinsurance for my chemotherapy treatment Can’t pay my $3,000 deductible for surgery….

The Patient Experience: Through the Cancer Lens

Premium Indiv.l Age 50 Fam 4, Age 30 Med Ded Drug Ded Med Ded Fam Drug Ded Fam OOP Max OOP Max Fam Specialist In/out Ptnt Fac. (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 $225.83 $512.10 $3,600.00 $0.00 $7,200.00 $0.00 $3,600.00 $7,200.00 5 visit@ $35, 0% after ded 0% 0% post ded $215.72 $489.18 $4,400.00 $0.00 $8,800.00 $0.00 $4,400.00 $8,800.00 5 visit@ $35, 0% after ded 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

• 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

Before a cancer diagnosis…

The Patient Experience: Through the Cancer Lens

The Patient

After a cancer diagnosis…

The Shopper

• Need to be sure I can afford

my premium AND deductible

• Are all of my oncologists in-

network?

• Are my drugs on the formulary

and can I afford them?

• What is my cost sharing for CT

scans, PET scans, MRI’s?

I paid a higher premium to avoid up front deductible for chemo

I could only access a provider list AFTER I bought the plan.. My oncologist is covered as a “tier 2” provider. Couldn’t find my IV drug on the formulary and my oral drug had a 20% coinsurance, which turned out to be $2,000 per month! 30% coinsurance, who knows what my bill will be????

The Patient Experience: Through the Cancer Lens

• 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

After a cancer diagnosis…

• 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.

The Patient Experience: Through the Cancer Lens

Thank You! Thank You! Thank You! Thank You!