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Payers Need to Invest More to Improve Outcomes in the Long Run

February 23, 2021

MitchBy Edan Stanley

Mitch DeKoven, MHSA, senior principal, health economics/outcomes research, real world insights, IQVIA, explains that while payers are used to certain mandates—such as the latest measures requiring health plans to provide access to preventive HIV care—they will need to make more investments into education and outreach for patients to receive the full clinical benefit.

According to the CDC, less than 10% of eligible users in the United States are currently taking preexposure prophylaxis (PrEP) to protect against HIV infection. Based on scientific evidence, the US Preventive Services Task Force provided recommendations and assigns grades to preventive services. From these recommendations, it was recently mandated under the ACA that health plans cover preventive HIV drugs for eligible patients—specifically people at high risk of HIV. Now that the measures have gone into effect, health plans face the challenge of implementing coverage and educating their members on the available resources. Mr Dekoven offered his insight and suggests how payers can address the task moving forward. 

Can you comment on the US Preventive Services Task Force’s recommendation in support of preventive HIV care, which led to increased access via an ACA mandate on health plans?

Any mandate that health plans need to cover certain drugs, or classes of drugs, is significant. The initial thought relates to the upfront cost as such but the use of such drugs at the outset likely serve to reduce any downstream costs if the condition is not treated correctly.

Can you identify some of the top barriers to care and access for patients with HIV? What role does cost play? 

As the Andrews piece describes, cost plays a significant role in obtaining HIV drugs. Beyond just HIV, there remains a lack of understanding as to how well patients understand their health plan and all of the benefits that it offers.

What challenges do you expect payers to face under these measures? 

Payers are used to certain mandates. It equates to making an investment in a therapeutic area, with the goal of saving money over the long term. For such an up-front investment, payers will want to ensure that patients are adherent to the medication in order to enjoy the full clinical benefit. This may require education and outreach.

What can payers do to better to make their members more aware of resources available to them? 

Be it television, social media or other outreach, it behooves payers to reach out to their enrollees so they can take advantage of such resources and improve their overall health.

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