Study: Some Insurers Using Rx Costs To Discourage Sicker Patients
Some insurers might be designing prescription drug benefit plans in a way that intentionally discourages sicker patients from signing up, according to a study published Wednesday in the New England Journal of Medicine, the Washington Post's "Wonkblog" reports (Millman, "Wonkblog," Washington Post, 1/28).
Under the Affordable Care Act, insurers cannot use pre-existing conditions to exclude individuals from their plans. However, formularies that insurers use to design their drug coverage plans can be designed to be less affordable for patients who will require costlier medications, according to Reuters. Insurers can choose formularies in which medications for patients with certain pre-existing conditions are more costly to discourage these patients from enrolling.
Researchers from the Harvard T.H. Chan School of Public Health analyzed 48 silver plans available in 2014 through the ACA's federal exchange in 12 states (Begley, Reuters, 1/28).
The researchers found evidence of what they called "adverse tiering" for HIV drugs in 12 of the 48 plans. As a result, patients in those plans are required to pay at least 30% of the cost of such drugs (Thomas, New York Times, 1/28). Because of that, researchers found that annual drug costs in those 12 plans were $4,892 -- or about three times higher than in other plans, in which annual drug costs were about $1,615.
The authors noted that adverse tiering can also apply to other chronic conditions, such as cancer, diabetes, mental illness and rheumatoid arthritis (Kennedy, AP/San Francisco Chronicle, 1/28).
Study lead author Douglas Jacobs said, "That's really a large cost difference," adding, "and really is a very significant financial constraint for those with chronic conditions, particularly HIV" (New York Times, 1/28).
America's Health Insurance Plans spokesperson Clare Krusing said, "[T]he analysis ignores a critical component of the marketplace: consumer choice," pointing out the range of plans available on the marketplace.
CMS spokesperson Aaron Albright said, "Plans are prohibited from discriminating against individuals with significant health needs in their benefit design," adding that CMS "analyze[s] plan information submitted by insurance companies to uncover discriminatory benefit designs, and work[s] with outlier plans to update formularies so they do not discourage enrollment of consumers with specific medical conditions" ("Wonkblog," Washington Post, 1/28)
Federal Investigation Already Underway
The practice of charging sicker patients higher out-of-pocket costs for prescription drugs already is the subject of a federal investigation (New York Times, 1/28).
CMS in December 2014 launched an investigation into prescription drug plans and other health benefits offered by insurers to determine whether companies are discriminating against people with chronic conditions such as AIDS, mental illness and diabetes. The investigation came about because of complaints filed by several patient advocacy groups.
In a letter to insurers, CMS warned that a plan could be discriminatory if its list of approved prescriptions excluded all treatments for a certain condition or if it restricts access to those drugs by requiring considerable copayments or prior authorization (California Healthline, 12/23/14).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.