In these tough economic times, many people are barely making ends meet, saving a dollar here or there in order to just get by. The situation is even worse for the thousands of Mainers who suffer from a chronic condition or progressive disability or disease such as multiple sclerosis, arthritis, cancer, hemophilia, Crohn’s disease, lupus and others — diseases that require expensive therapies or medications.
The medications are necessary to maintain optimal health, control symptoms, slow disease progression and even save lives. But often, individuals are forced to choose between paying for their medication and paying for their food.
In response to rising health care costs, insurance companies are introducing a tiered system for certain expensive therapies and medications. Tiering, accompanied by what’s called co-insurance, forces the patient to pay a percentage of the drug’s total costs — often up to 33 percent.
For some patients, this can amount to more than $1,000 monthly. This occurs despite the fact that the patient has paid his or her insurance premium, month after month, year after year.
Insurers claim it’s a cost-saving effort because patients can use drugs that are cheaper, such as generics. The problem is, for many of these specialty therapies, there are no generics.
What’s especially frightening is the use of specialty tiers, or excessive cost-sharing for medicine, is a rising trend nationwide. In 2009, the Kaiser Family Foundation reported that 87 percent of Medicare Part D plans used specialty tiers. And private insurers often follow Medicare’s lead. In fact, according to the Pharmacy Benefit Management Institute, 10-15 percent of private insurers around the country have already instituted a tiered system for medications.
Research shows that as out-of-pocket expenses increase, patients abandon or reduce medication doses. A study published by Gleason and colleagues in the Journal of Managed Care Pharmacy showed that when patients with rheumatoid arthritis faced a co-insurance payment of more than $100, many simply stopped taking their medication. The same study found that patients with multiple sclerosis who had a cost-sharing burden greater than $200 per month stopped taking their therapies.
A recent Consumer Reports survey found nearly 50 percent of Americans taking at least one medication have skipped filling their prescriptions, took less medication than prescribed or failed to undergo a medical test in order to save money.
Specialty tiers fly in the face of how insurance is supposed to work. If you pay your premium, you should be protected, or there should at least be a cap on a patient’s out-of-pocket expenses.
If patients skip medication or stop taking doses because they can’t afford it, that’s not cost- saving. In the long run, that’s more expensive for everyone because the patient ends up back at the doctor’s office or the emergency room.
We applaud Maine’s Legislature for attempting to put a stop to escalating costs for specialty therapies and medications. In this current session, lawmakers will vote on LD1691 to prohibit insurers from charging a greater co-insurance rate for these drugs than for other nonpreferred drugs.
Without these protections, insurance companies can make critical medications inaccessible for so many people. We urge legislative leaders to act in the name of protecting patients disproportionately affected by the practice of specialty tiers.
Courtney Cezair Mayers of Falmouth is the Arthritis Foundation advocacy ambassador and Robert Picone of Kennebunkport is a member of the board of trustees of the National MS Society, Greater New England Chapter.
Remember one thing about insurance companies. They are not in business to help their clients. They are in business to keep as much of their clients money as possible.
Hand wringing and moaning and groaning about the evils of universal health care reform; a program that will deliver meaningful relief on drug costs, morphs into a single state (Maine) trying to legislate drug pricing. It doesn’t have a chinamans chance of effecting meaningful drug price reform. The drug companies will wet themselves laughing. A single state legislature posturing like such is like King Canute trying to hold back the tide.
This case, if not overturned, can prove the path for others to enact provisions that keep costs down.
The exclusive rights of sale deals make generics for many drugs legally unavailable to citizens of the US, even though some of the drugs are available internationally with prices as much as 1000% less. Drug companies in the US buy supplies internationally, but citizens are not allowed to shop on the international “free market”. The “extra help” with Medicare D figures percentages on the US manufacturers suggested price, so the patient amount is based on inflated prices. Compared to the international market, for two chosen prescriptions, the extra help program costs about $350 more than buying the medication outright internationally, with no “help”.
We’ll see if it works.
As a person with MS who is being devastated by the high tier drug formulary and co-pay from my insurance company for a “specialty” biologic drug, I’m sure that the insurance companies will find a way around it IF it even passes during the current administration.
Many specialty drugs for what are called “orphan diseases” have extended patents due to the high cost of research and development. There are no generics and in some cases, the pharmaceutical company that develops a biologic drug owns the rights to every step involved in the manufacturing of the drug and no other company can make a generic.
There’s also a drug company that makes a specialty drug, who paid off their competitors who were prepared to make a generic of the drug when it went off patent. They changed the drug by ONE molecule, walked it through three years of FDA trials and sold it for a slightly lesser price, all while doubling the price of the old drug. The insurance companies forced patients off the drug that worked for them and on to the newer drug and the pharmaceutical company held on to the profits.
They were charged with price fixing, along with the generic manufacturers who went along with it and eventually they all received a slap on the wrist and they all laughed all the way to the bank..
…and people wonder why our healthcare system is broken and why the cost of healthcare is rising beyond the means of ordinary Americans.
” disease such as multiple sclerosis, arthritis, cancer, hemophilia, Crohn’s disease, lupus and others” Lupus? Its never Lupus, right Dr. House?
Another proposed government insurance mandate with the best of intentions but in effect requires insurance companies to cover and pay for more costs.
And everyone will cry foul when the price of insurance rises to cover the additional expense.