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Capitation & Hemophilia Treatment

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Capitation & Hemophilia Treatment

Capitation & Hemophilia Treatment

With health care costs continuing to rise and state governments struggling to balance their budgets, a growing number of public and private insurers have explored capitating costs for prescription drugs.  While the concept is not new, as the practice expands, it potentially affects how insurers treat clotting factor therapies.

Clotting factors therapies are crucial, life-saving treatment for individuals with hemophilia and other inherited bleeding disorders. Patients require a lifetime of treatment, and prescription drug costs for treatment can cost as much as $300,000 and exceed $1,000,000 per year, depending on the severity of the condition and whether there are any complications. Additionally, as biologics, each brand of blood clotting therapy has unique attributes, for which there are no generic equivalents.  

The “cost effectiveness” of capitating clotting factor treatment can actually have the opposite effect on the health care system, as physicians are forced to implement less than optimal treatment plans for patients to ensure that treatments are covered by insurance. As a result, patients could require additional ER visits as well as prolonged hospitalizations, thereby increasing immediate and long-term costs to plans and the health care system. 

NHF believes that capitation of clotting factor prescription drug costs would negatively impact existing standards of care and treatment. Furthermore, an independent, third party study of the potential fiscal impact of this issue commissioned by Hemophilia of Indiana in 2006 concluded that the special characteristics of health care costs associated with hemophilia made it ill-advised for insurers to pursue capitation of clotting factor as a cost-saving initiative. Download a copy of the Actuarial Opinion on Issues in the Capitation of Hemophilia.

Thus, NHF continues to work with public and private insurers, local chapters, and other partners to identify alternatives to capitation for the safety and benefit of the community.