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Specialty tiers deny fair health care

POSTED: August 17, 2011 6:00 p.m.

The perception of arthritis is often that it typically affects the elderly or injured. However, it is worth noting that in Georgia alone, there are about 9,200 children younger than 16 suffering from the painful joint swelling and stiffness that plagues those with juvenile arthritis. According to The Arthritis Foundation, more than 300,000 children have been diagnosed nationwide.
As we advocate and raise awareness about juvenile arthritis, one of the major issues that must be brought to light is the cost associated with treating the condition and what we can do to help with that burden.
As with many other chronic conditions, juvenile arthritis is expensive to treat. While many groups have been formed to help raise awareness and funding for these children, some insurance companies have put many effective arthritis treatments in “specialty tiers.” These specialty tiers are subject to astronomical out-of-pocket costs that must be paid by the patient. The result is that it makes it extremely difficult or impossible for some of our states most afflicted.
Specialty tiers work this way: In an effort to cut costs, many insurance companies have adopted a tiered payment system charging higher out of pocket coinsurance fees for more expensive medications. In most cases, when health insurance is purchased, there is an agreed upon, fixed co-payment amount for most medications. However, when certain newer, more expensive medicines are prescribed, the insurance company decides that should be in another tier, different from what was originally agreed upon, and charges the patient extreme amounts.
While this often is couched as cost sharing, it actually is denying those in critical need of certain medications from the financial protection that is supposed to be guaranteed by their insurance policies. Unfortunately, medications on higher tiers, which can reach out-of-pocket costs as high as 35 percent of the cost of the medicine, are often the medications needed to treat such serious chronic illnesses as rheumatoid arthritis, multiple sclerosis and hemophilia.
Clearly, this system is putting those with the greatest need at the greatest risk and in even greater debt. When patients aren’t able to afford their medicine, they stop taking it. When patient adherence to medicine declines, their health is jeopardized.
The facts speak for themselves. A recent study by Prime Therapeutics indicates that an out-of-pocket cost greater than $200 was associated with at least six times as many cases where patients declined to fill prescriptions compared to an out-of-pocket cost of $100 or less.
A 2007 analysis by RAND Health reviewed more than 900 studies for the relationship between cost sharing and drug utilization. The analysis found that for every 10 percent increase in cost sharing requirements, drug utilization decreased between 2 percent and 6 percent, depending on drug class and patient health status.
While the passage of the recent health-care bill provides patients with many protections, out-of-pocket prescription medication costs still are not part of those protections. Steps must be taken to prohibit or stem the practice of specialty-tiered coinsurance to fully protect patients.
Georgia Congressman Hank Johnson and other members of Congress have jumped on this cause.
They recently wrote a letter to the administrator of Medicare and Medicaid services: “We are troubled by the proliferation of ‘specialty tiers’ for high-cost drugs that treat conditions such as rheumatoid arthritis, multiple-sclerosis and hemophilia. Unlike generic and preferred-brand drugs that generally require co-pays, therapies placed on a specialty tier are subject to coinsurance, requiring the beneficiary to pay a percentage of the drug’s cost. This can amount to patients having to spend thousands of dollars to obtain needed medication, leading many to forego or alter treatment and suffer worse health outcomes that ultimately increase costs for Medicare and the health-care system overall.”
Johnson, who plans to introduce specialty-tier legislation, is taking a noble first step on the federal level, but this practice also must be addressed on a state level through the office of the Georgia Insurance Commissioner and elected officials enforcing a patient-protected legislative policy.
While these insurance practices are being done in the name of saving money, the practice ultimately will raise costs due to an increase in physician and emergency-room visits. That is bad economics, bad policy and bad medicine.

Leone-Glasser, RN, HHC is president of Advocates for Responsible Care in Atlanta.

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