How U.S. health care emerges from the COVID-19 pandemic is a million-dollar question, as patients, providers, payers and drug manufacturers are adapting to a new reality that’s advancing telehealth and changing how providers interact with patients.
Part of that change could be more patients switching from Medicare Part B drugs that have to be administered by a provider to home infusion or Part D drugs that are picked up at the pharmacy or delivered to the patient’s house.
People with autoimmune diseases are among those who would be most impacted by such switches, but the market-driven changes also could disrupt how Americans, in general, pay for therapies and make manufacturers rethink how their drugs are administered.
The changes also are likely to reenergize concerns about drug pricing and push Congress to do more than talk about redesigning the Medicare Part D program, Mike Schneider, a principal for commercialization and regulatory strategy at Avalere Health, said Thursday during an Avalere webinar on shifts from Part B to D in the autoimmune space during the pandemic.
It will be awhile yet before the data are in on how COVID-19 has impacted the health care system, but early data show doctor visits are down, meaning that use of Part B drugs likely is being impacted, said Kayla Amodeo, an associate principal for policy at Avalere.
Amodeo cited early data from an arthritis registry in which 48% of respondents indicated that, because of the coronavirus, they had postponed scheduled appointments, delayed treatment or stopped their treatment without consulting their doctor.
The response is understandable. Patients with autoimmune diseases are at risk of complications from the coronavirus, so they’re less likely to visit their doctor or schedule an infusion during the pandemic. However, switching to a Part D drug is not a simple solution, except, perhaps, for those being treated with Part D drugs such as Johnson & Johnson’s Remicade (infliximab) or Stelara (ustekinumab), which have a Part D formulation.
There is no one-size-fits-all treatment for people with autoimmune diseases. While some may do well on a Part D drug, others may not. And any change in treatment requires careful monitoring, Amodeo said. Telehealth can help address that issue, she added.
But other switching issues could prove more challenging. For Medicare patients, nearly all drugs used to treat autoimmune diseases require prior authorization, Schneider said. Getting authorization through a Medicare plan can take time.
Then there’s paying for the drug. Medicare reimburses Part B therapies differently than Part D drugs. Beneficiaries have a 20% copay for Part B services, but many of them have supplemental plans that help with those costs, Schneider said. Part D drugs have a 25% to 33% Medicare copay, so patients’ out-of-pocket cost for drugs with list prices in the hundreds or thousands of dollars can be significant until they hit the catastrophic threshold. Medicare also prohibits patients from using coupons or other manufacturer patient-assistance programs to help with those costs.
A switch could be easier for patients covered by commercial plans, which are likely to approve prior authorization requests more quickly than Medicare, Schneider said. And private plans are more flexible in allowing patients to accept manufacturer assistance.
Out-of-pocket costs are a big consideration. Patients faced with higher out-of-pocket costs are more likely to abandon their prescriptions, said John Linnehan, practice director of health economics and advanced analytics at Avalere. “That’s a concern from a patient perspective,” he noted.
Patients aren’t the only ones who would be impacted by switches from Part B to D drugs. Large-scale switches would hit the bottom line for providers, as Part B reimbursement can be a significant revenue stream for them, Linnehan said. The pandemic will have turned providers’ worlds upside-down if it leads to more reliance on home infusion and Part D drugs in the future, he added.
On the other hand, an enduring switch to Part D drugs could be a positive for plans and pharmacy benefit managers, which benefit from manufacturer rebates. Part B drugs typically don’t have big rebates, Schneider said, but Part D drugs do.
Aside from B-to-D switches, the pandemic has jarred traditional business models in other ways. Sarah Butler, head of Avalere’s client solutions team, noted that new-to-brand prescriptions are down 41%. That can hurt, especially with new drugs.
Manufacturers typically invest millions of dollars to ensure patients get access to new drugs, Linnehan said. Thus, delays in prescriptions are creating business risks. To survive, manufacturers have to be smart and mitigate the risks when the pandemic ends, he said.
Part of that will be understanding how things have changed. Due to people delaying treatment and even diagnosis, patients going to doctors when the pandemic ends likely will be at later disease stages, Schneider said.
How doctors interact with patients, as well as their colleagues and staff, also will change, Amodeo said. The pandemic has jumped telehealth forward, as it allows patients to access health care on their terms, she explained. They will expect that to continue.