Insurers Shift Costs and Facts

BIOtech Now
Andrew Segerman

As health insurance companies begin setting rates for 2019, many consumers are once again faced with skyrocketing premium hikes. Here’s how the insurance industry is responding.

Continuing to Deny Coverage

A new study from the University of Pennsylvania (UPenn) School of Medicine finds that insurance denials for hepatitis C drugs among patients with both private and public insurers remains high across the United States. As Dr. Vincent Lo Re III, associate professor of Infectious Disease and Epidemiology at the UPenn School of Medicine, explains:

“Despite the availability of these newer drugs and changes in restrictions in some areas, insurers continue to deny coverage at alarmingly high rates, particularly in the private sector.”

Vincent continued: “It warrants continued attention from a public health standpoint to have more transparency about the criteria for reimbursement of these drugs and fewer restrictions, particularly in private insurance and certainly to continue the push in public insurance, if we want to improve hepatitis C drug access across all states.”

The truth is, new therapies are delivering more than a 90 percent cure rate for hepatitis C, saving our health care system billions in reduced hospital costs, pain and suffering for patients. But what good is a breakthrough treatment if your insurer won’t help pay for it?

“Eliminating hepatitis C in the U.S. is a feasible goal,” Lo Re said, “but that’s going to be hard to achieve if payers are not reimbursing for the treatment.”

Denying patients medicines – and hope – is common practice for the insurance industry, and Sarah Benoit, a patient with ALS, knows this struggle all too well. Without insurance, Sarah can’t afford the price of Radicava, a breakthrough treatment that “could slow the decline [of ALS] in function — by about 33 percent.” Sadly, her insurance provider has denied access to the drug, even though it was approved by the Food and Drug Administration.

“Unfortunately, the [insurance] process is difficult,” Dr. Haatem Reda, a Mass. General neurologist noted. “It’s been a struggle for a lot of my patients to get Radicava. Even for those who are eventually approved, they go through a grueling process.”

Increasing Patients Out of Pocket Costs

As we see time and time again, health insurance providers and pharmacy benefit managers (PBMs) have been shifting a much greater portion of prescription drug costs to patients and consumers. These requirements can cost thousands of dollars out of pocket and often result in limited access to essential medicines. For starters…

To offset these costs, many pharmaceutical companies offer programs that assist patients with their out of pocket costs, including deductibles and co-pays, for their prescriptions. But naturally, no good deed goes unpunished. Insurance plans and PBMs have started to implement so-called “copay accumulator” programs, which prevent funds provided by these assistance programs from applying to a patient’s out of pocket maximum or deductible. This can leave patients with steep costs when the value of patient assistance is exhausted.

NPR recently shared the story of one such patient. Kristen Catton is a nurse case manager in Columbus, Ohio who suffers from multiple sclerosis. The treatment prescribed to Kristen was subsidized significantly by the drug manufacturer through a copay assistance program – a series of financial contributions made by the drugmaker to help patients afford their medicine while paying down their health insurance deductible. These payments often continue until the individuals’ deductible and out-of-pocket maximum limits are reached, at which point the health plan picks up the rest of the tab.

Unfortunately, copay accumulator programs newly put in place by health plans are leaving Kristen and many other patients taking expensive medicines with payments they simply can’t afford – in Catton’s case, that’s nearly $4,000 a month. This emerging practice prompted a group of 60 HIV/AIDS advocacy groups to send letters to state attorneys general and insurance commissioners to investigate the issue. As Los Angeles Times columnist David Lazarus recently observed:

“Co-pay accumulators allow insurers to double dip: They get their full co-pay and they get to extend the duration of patients’ deductibles.”

Distorting the Facts, Again

The insurance industry – represented by America’s Health Insurance Plans or AHIP – is out with its annual report showing how a health care premium dollar is spent. And given the complexity of health insurance, this annual analysis could be useful – if the numbers weren’t simply an attempt to distort the facts. As Dr. Adam Fein of Drug Channels Institute has noted, “Fake news alert: the AHIP analysis is misleading and deceptive.”

We’ve debunked their inflated “23 percent” number before – which is used time and time again to perpetuate the narrative that prescription drug spending is the major driver of premium increases. Unfortunately for them, tons of recent data proves just the opposite: prescription drug prices are growing quite modestly – and even falling on a net basis for some payers. Don’t believe us? Just ask insurer-backed PBMs like CVS Health and Prime Therapeutics and Express Scripts – all of which reported remarkably stable or even declining drug prices for commercial plans in 2017. Even the non-partisan Centers for Medicare and Medicaid Services confirms this steady trend.

Here’s a number that’s not inflated: 6,000. That’s how many new medicines the biopharmaceutical industry has in development for a wide range of life-threatening or debilitating diseases. We’re doing our part – it’s time for the insurance industry to do theirs and allow patients to obtain the medicines they need with out-of-pocket costs they can afford.

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