A pharmacist uses a spatula to count pills for a prescription. Photo by Senior Airman Thomas Karol/U.S. Air Force
Maryland patients, particularly those living with chronic health conditions, need consistent access to medications that manage symptoms and enable them to live healthy and fulfilling lives. Patients often have to navigate a complicated health system where multiple health system middlemen impact that access, and what patients pay at the pharmacy.
As the Maryland Prescription Drug Affordability Board (PDAB) examines high medication costs across the health system, board members must ensure that Maryland patients are ultimately the ones benefiting from any efforts to lower health care costs and realized savings.
Established in 2019, the Maryland PDAB identifies and reviews medications that have high list prices. The board can also impose policies to rein in costs for drugs deemed to be unaffordable for Marylanders, using a tool known as an upper payment limit (UPL).
A UPL is a limit on what an insurance company or government health plan can reimburse doctors, infusion centers and clinics for treatments they acquire to administer to their patients. Currently, the Maryland PDAB has the authority to set a UPL on a handful of drugs for Maryland patients who have insurance through state and local government health plans.
A UPL is not a cap on what patients pay out of pocket, but instead caps the reimbursement rate for a drug in the state. Our fear is that setting these limits too low could also limit what treatments are available to patients.
If reimbursements from health plans are too low, doctors and clinics may not be able to afford to provide patients with access to a treatment that has a UPL. Additionally, assistance programs already ensure that many patients have low out-of-pocket costs to treat rheumatic diseases – meaning that implementing a UPL could threaten to disrupt access to treatments that patients are able to afford.
There is no one-size-fits-all treatment for patients living with chronic and complex health conditions, and many patients often spend years identifying the treatments that work for them.
– Tiffany Westrich-Robertson
The Maryland PDAB is conducting cost reviews on six medications, including those that treat chronic illnesses such as diabetes, asthma and psoriatic arthritis. As the PDAB assesses whether these drugs are affordable for Maryland patients, it is crucial that they listen to patients and patient organizations to fully understand the patient-reported value of these treatments and the context behind why some find them affordable.
Moreover, before any UPL is put in place, the board must engage with all stakeholders to truly understand the potential long-term outcomes and to provide assurance to patients that access to their medication will not be compromised as a result.
As a patient living with axial spondyloarthritis – an autoimmune and autoinflammatory arthritis disease that affects my whole body, largely spine, pelvis and feet – I need consistent treatment and rely on specific medications to alleviate painful symptoms and maintain my desired daily routines. For patients living with conditions like mine, waiting for or losing access to an effective therapy can cause harmful health consequences, including developing comorbidities as a result of inadequate or suspended treatment.
There is no one-size-fits-all treatment for patients living with chronic and complex health conditions, and many patients often spend years identifying the treatments that work for them.
PDABs are new, with trial-by-error processes, so we do not yet understand the impact that their policies will have on patients. I worry that the board will make decisions on behalf of patients who can actually afford these medications instead of identifying true causes of affordability and access and making recommendations to address those instead.
As the Maryland PDAB continues assessing the costs of certain medications that patients living with chronic conditions rely on, it is critical that policies intended to lower health care costs do not impede access to treatments or lead to fewer options for patients.
Policies that the Maryland PDAB can institute would impact many health care stakeholders in the state – including state health plans, doctors, clinics, and more. But ultimately patients who rely on these medications to live their lives every day should be the main priority.
Should the PDAB move forward with setting UPLs on any of the medications they are examining, patients may end up being the ones left behind.