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.