Out-of-Pocket Costs and Patient Access to Therapies in Insurance
A recent survey by Nuvera Life Science Consulting, presented at the InformaConnect meeting focused on Patient Assistance and Access Programs in Philadelphia, highlights the profound impact of out-of-pocket costs on patient decisions regarding new therapies. According to the study, approximately 25% of patients may opt out of initiating a prescribed therapy due to expenses between $50 and $100. Additionally, 41% of patients who choose not to fill their prescriptions cite financial burden as a primary reason.
Corey Ford, a principal at Nuvera, emphasized that exorbitant out-of-pocket expenses are a critical barrier preventing patients from obtaining initial medication fills. He cautioned that imminent changes in healthcare policy, payer-driven adjustments, and funding expirations could significantly disrupt patient access programs in the near future.
The “One Big Beautiful Bill Act,” implemented on July 4, 2025, has already begun to reshape the insurance landscape. This legislation failed to renew the enhanced premium tax credits from the Affordable Care Act, resulting in a reported drop of 1.4 million in marketplace enrollment. Consequently, insurers have been forced to adopt narrower benefit designs in their exchange offerings. Corey Ford noted that silver plan subscribers without cost-sharing subsidies experienced a deductible increase of over $400 this year.
Medicaid revisions under this legislation further compound these challenges, with federal funding for Navigators drastically reduced. These advisors, essential for assisting individuals through ACA processes, have seen budget cuts of up to 90%. Additionally, upcoming changes from the Centers for Medicare & Medicaid Services may raise catastrophic plan out-of-pocket maximums and eliminate standardized plan structures.
An analysis by the Congressional Budget Office, highlighted by Mr. Ford, anticipates that up to 10 million Medicaid beneficiaries could lose coverage by 2034. This decrease results from expired subsidies and regulatory compliance alterations, compounded by insurance losses in other groups. States may face difficult decisions regarding Medicaid eligibility and coverage, particularly those that have previously expanded Medicaid.
Employee contributions to employer-sponsored premiums have surged by 26% over five years. Cost-sharing for specialty drugs remains high, with averages reaching 27% for employers and nearly 50% on the insurance exchanges. Disenrolled Medicaid recipients transitioning to exchanges will encounter significantly higher out-of-pocket costs, intensifying the demand for patient assistance and copay support programs.
Mr. Ford also noted the increasing prior authorization delays in Medicare Part D, with 75% of plans aiming to narrow formularies and enhance requirements such as step therapy in certain treatment areas like rheumatology and weight management. The shift of infused therapies to pharmacy benefits, where patient cost-sharing tends to escalate, further complicates access. Comprehensive education strategies are needed to address these challenges, akin to those used for Part D benefit redesigns. Legislative efforts, such as the Help Ensure Lower Copays Act, face uncertain approval despite some bipartisan support. No financial disclosures were reported by Mr. Ford in relation to these survey findings or insights.