Richard Pezzillo: Insurers, pharmacy benefit managers are squeezing patients

For the Monitor
Published: 4/21/2018 12:09:50 AM

It is no secret that health care costs continue to rise, with premium increases topping 58 percent since 2006, according to the Kaiser Family Foundation. What may surprise lawmakers in Concord is that patient out-of-pocket costs, such as deductibles, co-insurance and higher specialty pharmacy tiers, have outpaced premium increases by four times.

These cost-shifting tactics by health plans such as United Healthcare, Blue Cross Blue Shield and Aetna, to name a few, and pharmacy benefit managers, such as Optum Rx, CVS Caremark, Express Scripts and others, are implemented under the guise they “create better health care consumers.”

In response, manufacturers began offering assistance programs to enable patients to access their life-saving specialty medications.

But now, these insurers and pharmacy benefit managers are doubling down and squeezing patients even more, targeting these assistance programs by allowing patients to use manufacturer co-pay assistance, but no longer counting it toward meeting their high deductibles and out-of-pocket costs.

So, for many, the only means available for them to access their life-saving treatments is at risk. Scary? Yes. Surprising? Sadly no.

High-deductible health plans require patients to meet their entire deductible before the plan will contribute a dime, at which time many plans then require co-insurance, which can be 20 percent or greater until the maximum out-of-pocket expense is met. For reference, the Affordable Care Act annual max out-of-pocket in 2018 is $7,150 per person, $14,300 per family.

Let’s work through the following example:

You have a $6,000 deductible. Your monthly life-saving medications cost $10,000. There is manufacturer assistance available, up to $18,000 annually. In January, you could use the assistance to pay the $6,000 deductible, which would then trigger the insurer to begin paying.

With these new accumulator adjustment programs, the insurer would not allow the assistance to help the member meet their deductible, so by end of month three when the assistance was exhausted, the member is still accountable for the entire deductible.

Fortunately, recognizing these co-pay assistance programs are a lifeline for patients, lawmakers decided not to pursue further restrictions on them. But that doesn’t mean pharmacy benefit managers and insurers can’t still change plan designs to include them, and that’s exactly what they’ve done.

A one-size-fits-all approach to save money simply doesn’t work. And, there’s no greater example of why than with the patients that I represent – those living with hemophilia.

Hemophilia is an inherited genetic condition that affects only about 1 out of 10,000 people. Hemophiliacs lack the ability to make one or more of the blood proteins involved in the clotting process. Without treatment, they bleed internally, sometimes as a result of trauma, but sometimes simply as a result of everyday activities. This bleeding can lead to severe joint damage and permanent disability, or even death.

Hemophilia cannot be cured but it can be controlled thanks to medication (“clotting factor”), a specialty drug that patients take prophylactically and/or on demand through intravenous infusions. But, a single treatment typically costs thousands of dollars, and individuals often require multiple treatments each week, if not daily. There is no way to incentivize hemophilia patients to use a less expensive treatment, because there are no cheaper treatments – there are no generics available. The same goes for several other chronic diseases. And in many cases, even when there is a generic available, patients have tried those, and they don’t work.

Co-payment programs don’t increase the demand for clotting factor, or drive hemophilia patients toward more expensive therapies. The medical need for clotting factor is undeniable. Co-payment programs make it possible for patients to adhere to their doctor-prescribed course of treatment, and help patients avoid the painful, potentially disabling and costly complications of non-adherence. Co-payment assistance programs provide an essential lifeline to the hemophilia community and many other chronic disease patients.

(Richard Pezzillo is the executive director of the New England Hemophilia Association, which assists and advocates for patients with a bleeding disorder.)

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