Confronting demand for health care affordability and access to care

Members are aware of the many barriers impacting access to care, but name affordability as their chief concern. While plan sponsors prioritize affordability and access, there is room for improved coordination.

Affordability across many industries is a common concern in the market – while both members and plan sponsors grapple with how to do more with less. Health care is definitely no exception. Our latest research showed that 49% of consumers noted cost-related challenges as the top problem facing the American health care industry today.

In partnership with Ipsos, Evernorth conducted a nationwide survey of more than 3,600 consumers, employers and health plan leaders to understand the challenges at the forefront of health care today. Research findings highlight specific concerns plan sponsors need to keep in mind to stay ahead of market dynamics, specifically affordability and accessibility.

Drug formularies help reduce health care costs

Generic medications often serve as a more affordable solution for those needing prescription drugs. Over the last several decades, generic medications have become increasingly popular among patients and physicians, who are almost universally comfortable prescribing them. In fact, 95-97% of respondents say they are likely to switch to a generic medication if recommended by a physician.

Biosimilars can also lower costs in the pharmaceutical market. In fact, up to 40% of respondents stated that they saved up to 40% with biosimilars over their reference product. Biosimilar medications are safe, clinically equivalent drugs that closely resemble existing biologic products. With many biosimilar drugs in the pipeline, plan sponsors can expect better health outcomes, greater access to care and lower costs for consumers in the near future, as the result of the global market effect of more competition.

Plan sponsors can specifically select one of our national standard formularies, including the National Preferred Formulary (NPF), one of the industry’s most powerful ways of providing access to affordable medications while preserving member choice. Members are at the heart of everything we do, and it is important to provide a range of medication options for the best outcomes. Of the thousands of generic and brand name medications available in traditional pharmacy benefit coverage, more than 87% are available on the NFP. Preferred drugs often include generics, biosimilars, or competitively priced branded medications that offer the greatest clinical benefit to patients and often help them save money at the pharmacy.

With clinical appropriateness as our primary concern, we utilize clinical experts and committees to review specific medications and consider drug cost effectiveness. By preferring clinically appropriate, lower-cost medications and excluding high-cost alternatives that don’t provide additional clinical value, the NPF has saved plan sponsors $29.4 billion since 2014. Plan sponsors can choose the formulary that's right for their plan and member population.

Plan sponsors can help address demand for health care access and affordability

Unsurprisingly, plan sponsors share their members’ concern with making the cost of care more affordable and manageable. They also agree that the cost of insurance, premiums and prescription drugs is too high. Plan sponsors should review utilization costs to understand where spend is high and work to employ solutions or programs to provide cost efficacious, quality care. Plan sponsors may also choose to customize cost-containment solutions to maximize savings. These optional solutions are offered separately, giving clients more freedom to design their benefit how they see fit. These solutions include, but are not limited to, value-based solutions, such as SafeGuardRX, Advanced Utilization Management, medical rebates with MedRX and SaveonSP.

In addition to ensuring affordability and offering customizable solutions, health plans and employers can also help with accessibility. Consumers want a flexible, supportive culture that prioritizes well-being. This is especially important for an employer with a high percentage of hourly workers who may be skipping wellness appointments as stepping away from work means forfeiting pay for that time. Thinking through access and care may require outside-of-the-box thinking such as offering a certain amount of ‘paid care hours’ a month or quarter where employees are supported to get their wellness exams but do not have to give up part of their paycheck.

Click here to access the full 2023 Health Care in Focus report.

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Express Scripts National Preferred Formulary
The National Preferred Formulary is the industry’s most powerful tool for payers to achieve optimum trend management while preserving plan members’ access to clinically effective generic and brand name drugs. Our drug formulary management strategy is rooted in five key principles: clinical appropriateness, flexibility, value, customization and choice.