Our Turn: Health insurance bait and switch must end

Published: 2/24/2020 6:15:12 AM

Many Granite Staters rely on constant and consistent access to their medications. For those living with multiple sclerosis, epilepsy and other complex and chronic medical conditions, there is no one-size-fits-all treatment option; the prescription medications that work well for one person may not work well for others.

Managing symptoms with medication requires careful evaluation and monitoring by both medical providers and patients, and it’s made all the more complex when factoring in potential side effects, routes of administration and other unforeseen complications. Finding the right mix of treatments is often a painstaking process of trial and error and can last for months or years and makes the process known as “non-medical switching” a dangerous one.

Non-medical switching refers to changes health insurers make to prescription drug benefits during the plan year, for reasons that are unrelated to patients’ health or safety. This practice may result in stable patients being forced to switch medications or even stop treatment due to unanticipated costs.

The cost of prescription drugs has been rapidly rising for years and losing coverage can have disastrous financial impacts to those living with chronic and complex conditions.

For example, MS disease modifying therapies (DMTs) continue to rise, and in 2019 the average wholesale cost for brand drugs was over $88,000. People often choose to enroll in a specific health plan based on the available information about the medications they need.

At the beginning of every year, many Granite Staters carefully and deliberately select an insurance plan to purchase based on coverage details and coverage of medically necessary services and prescriptions. Guaranteeing continuity of care, minimizing delays in access to treatment, and avoiding unexpected changes in health coverage are crucial to preventing significant negative health consequences, including the irreversible accumulation of disability.

Studies have demonstrated that people with epilepsy are at greater risk of seizure after a switch; individuals who switched their drug had a 16.7% rate of seizure recurrence at 6 months, compared to 2.8% among people remaining on the same drug.

Despite this, insurers are still allowed to make changes to coverage without regard to patients’ stability or what expert providers recommend as the best course of treatment. These mid-year formulary changes are also commonly referred to as “non-medical switching.”

Insurers can currently make several types of changes to their drug formulary during the plan year, such as moving a prescription to a higher cost-sharing tier, increasing out-of-pocket costs by moving from co-pay to co-insurance, adding utilization review requirements, such as step therapy or prior authorization, or removing a prescription from a drug formulary completely.

Under current New Hampshire law, a health plan must only provide 45-days’ notice to change its formulary. This notice period does little to prevent the loss of coverage that a patient may suffer. When patients are priced out of their physician-recommended medications, many are forced to abandon their effective therapy for a less costly and oftentimes less effective alternative.

Medications for MS, epilepsy, and other complex conditions are not interchangeable – they are highly individualized and require constant physician monitoring.

When patients are forced to change, limit or are denied access to medications that stabilize their condition, they can see irreversible damage done to their health and well-being, some potentially life-threatening.

While insurers will claim that these mid-year changes are necessary to offset rising drug prices, their solution does nothing to benefit the patients. The insured should not suffer the consequences of an issue that lies outside of their control.

People choose a specific plan for a reason, many doing so solely based on covered formularies. When a person signs up for a plan, they are essentially signing a contract. The insurers should be held responsible for sticking to it.

In the coming weeks, state senators will vote on a bipartisan package of bills to curb excessive drug price increases and bolster accessibility across New Hampshire. Individually, these pieces of legislation, which are supported by Gov. Chris Sununu and lawmakers on both sides of the aisle, aim to improve transparency, accessibility and affordability of prescription drugs.

And together, they represent a significant step forward in improving the health of the Granite State.

SB 690 is one piece of legislation under consideration that will specifically address the accessibility issue faced by many Granite Staters. This piece of legislation puts forth very important protections for health care consumers, preventing insurance companies from making harmful changes to their drug formularies during the policy year.

People who buy insurance cannot change the terms of their plan during the year so insurance companies should not be able to either. SB 690 would put in place critical protections for Granite Staters, and especially for those who cannot simply switch medications.

When people with complex illnesses must switch medications, or have a delay in access, they are at an increased risk of negative health outcomes that can become life-threatening. Not only does this issue risk the well-being of individuals, but complications in accessing prescribed treatments also come with significant cost to the New Hampshire health care system and economy.

Annually, failure to adhere to treatment regimens has caused approximately 125,000 deaths nationwide, accounts for at least 10% of hospitalizations, and costs the U.S. health care system between $100 billion and $289 billion, according to the Annals of Internal Medicine.

New Hampshire legislators have the opportunity to give the Granite State relief from the insurance companies’ increasingly common practice of unilaterally changing the plan’s coverage during the policy year. To ensure access to necessary drugs for Granite Staters, New Hampshire must work to guarantee stable and predictable drug prices throughout the plan year.

It is imperative we contact our legislators and urge them to support SB 690 to ensure that the health plan we signed up for remains unchanged to us throughout the entire contract year.

(Ayah Roda is the senior manager of Advocacy for New Hampshire for the National Multiple Sclerosis Society. William Murphy is the director of advocacy and public policy for the Epilepsy Foundation of New England.)

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