How Virginia can lower health care costs without sacrificing access to critical medications

How Virginia can lower health care costs without sacrificing access to critical medications

Virginians overwhelmingly support lowering health care costs, a problem that is particularly acute for the large number of residents living with chronic and rare diseases. Therefore, addressing health care access and affordability challenges remains a top priority for Virginia lawmakers during the 2024 General Assembly session.

Treat special medical conditions and address high medical costs

One patient group affected by high health care costs: patients with primary immunodeficiency (PI). PI patients suffer from one of more than 450 rare diseases What part of the body’s immune system is missing or not functioning properly. They are highly susceptible to repeated, persistent and severe infections. These infections can lead to debilitating illness that must be treated with intravenous antibiotics and/or hospitalization, and some infections are fatal. People with PI may also have autoimmune diseases such as irritable bowel syndrome, lupus, or rheumatoid arthritis. Finally, people with PI have an increased risk of allergies and certain cancers, including lymphoma and leukemia. Fortunately, most patients with PI can live healthy, productive lives if they receive lifelong immunoglobulin replacement therapy, an innovative, life-saving treatment derived from donated plasma.

Last few years, Virginia lawmakers seek to create Prescription Drug Affordability Board (PDAB) and this year’s Senate Bill 274 and House Bill 570 intend to do so. The proposed commission would be composed of health care experts with authority to identify prescription drugs that pose affordability challenges for patients and regulate drug prices by setting payment caps. State PDABs are a growing national trend.At least Eight states have established PDABs Other countries are actively considering legislation to create them.

Bipartisan supporters pledge to re-establish Virginia Prescription Drug Affordability Commission in 2024

Despite the best of intentions, many patient communities have expressed concern that these committees may have unintended consequences on access to critical medicines. The goal of PDAB is to reduce costs, but Virginians should ask who will see the cost savings and, more importantly, what impact will this have on patients?

The PDAB and its efforts to impose price limits could threaten patient access by discouraging investment in research and development of innovative, life-saving medicines that patients rely on. If drug manufacturers face state-mandated payment restrictions, it is expected to have a negative impact not only on access to current medicines, but also on future investments in research and development. These unintended consequences are objectionable and should make legislators cautious when considering the creation of a PDAB.

The health insurance ecosystem is incredibly complex. While the PDAB focuses on list prices and reimbursement rates for specific drugs, this does not necessarily correlate with the out-of-pocket costs that patients are most concerned about. Out-of-pocket costs not only impact a family’s budget, but also their ability to pay for necessary medications and other basic expenses. No one should have to choose between paying at the pharmacy counter and putting food on the table.

Other needed reforms

Virginia lawmakers have an opportunity to effectively address the high out-of-pocket costs that patients continue to face, and that starts with reforming the growing industry of middlemen known as pharmacy benefit managers (PBMs).

PBMs work with health insurance providers and have grown to be among the most influential decision-makers in health care access and affordability. PBMs dictate which drugs a health plan covers, out-of-pocket costs, and whether patients and doctors must jump through additional hoops (such as prior authorization or step therapy) to get the drugs. These strategies result in significant delays in patient care that can adversely affect health, increase costs for consumers, and increase administrative burdens on healthcare providers. Thankfully, legislation was introduced this year to address PBM practices, House Bill 1041. This measure would provide needed transparency into PBM practices and help Virginians save money.

Additionally, Virginia legislators can seek help from members of Virginia’s congressional delegation who are leading the effort Ban harmful practices and Solve PBM At the federal level.

In the health policy world, there is a lot of discussion about costs—the costs of state-regulated and state-funded insurance plans, out-of-pocket costs for patients, the cost of employer-provided health insurance, premium costs, and so on. But let’s not forget the value; specifically, the value that comes from access to life-enhancing and life-saving therapies. Equally important is the value of staying healthy enough to work and pursue our goals, contribute to our communities, and spend more time with family and loved ones. These should be the goals of our health care system, and I encourage our legislators to keep this value in mind as they debate these issues.

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