The consequences of high out-of-pocket medication costs

Bill RemakAdherence to doctor-prescribed treatment regimens is critical to the health of many baby boomers living with chronic conditions such as rheumatoid arthritis, multiple sclerosis, diabetes, lupus, hepatitis C, and many others. Increasingly, however, the cost of treatment is unnecessarily forcing this population - many of whom have limited incomes and are close to retirement - to choose between paying for their medications and paying for food, rent, or other necessities for their families and themselves. 

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Barriers

At present, a number of barriers stand between the more than 65 million U.S. baby boomers and affordable, timely access to medical care.

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Some health insurers, for example, have begun driving up patients’ out-of-pocket costs for vital medications, which is putting the cost of treatment beyond the reach of many patients.

Rather than pay a fixed, predictable copayment, many patients are now often forced to pay coinsurance - or a percentage of the total cost of the drugs.  For some patients, the cost of a single medication may mean hundreds or thousands of dollars in additional out-of-pocket costs every month. 

When patients cannot afford their medications, they either undertreat their conditions or stop treatment altogether. Nonadherence to physician-prescribed treatment regimens can lead to more rapid disease progression and deterioration in health.

Burdens

Unfortunately, the effects of burdensome out-of-pocket costs are not limited to the health of individual patients. When patients are forced to abandon their prescriptions, it can lead to increased healthcare costs to the system, in the form of unnecessary hospitalizations, emergency services, and physician visits.

Nonadherence results in $100 billion in annual direct costs to the healthcare system and $2 billion in annual lost patient earnings and productivity. 

Recommendations

As a cancer survivor, a two-time liver transplant recipient, and a diabetic, I take multiple medications. Often they are newer or produced in smaller quantities than other drugs are. Often, less expensive generic options do not exist. In these instances, I have no other choice but to take the brand-name specialty medication prescribed.

Fortunately, steps are being taken to help patients with similar circumstances. Patient advocacy voices, such as the California Chronic Care Coalition, which comprises more than 30 statewide California organizations representing people with severe chronic conditions or diseases, have urged state and national health officials to enact public policy to ensure affordability and access to specialty medication.

The efforts have not gone unnoticed.  As recently as last month, Covered California, the state health insurance exchange, received recommendations from various health insurance plans, healthcare providers, and patient advocate groups on how to improve quality, access, and affordability of specialty medications. 

The recommendations, which will be finalized and announced in the next several months, will establish caps for out-of-pocket cost for any one prescription and will increase transparency and improve available drug formulary information to better inform patients of coverage.

Actions

Last year, several states took action to cap patient out-of-pocket costs. For example, Montana’s insurance commissioner required the state’s four largest health insurance companies to cover all prescription drugs equally, in flat dollar copays, rather than require burdensome coinsurance or a percentage of the total cost of the drug.

On the federal level, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a final rule modifying how qualified health plans under the Affordable Care Act (ACA) will be designed for the future. The CMS rule prohibits discrimination in benefit design, which includes placing most or all drugs that treat a specific condition on the highest-cost tiers.

Stakeholders need to come together to examine the burden of patient out-of-pocket costs and to help ensure that patients have access to the care they need as they grow older. 

Bill Remak is founder and CEO of the California Hepatitis C Task Force and a founding board member of the California Chronic Care Coalition. He is an associate member of the Marin County Pharmacists Association. Contact him at wmremak@pacbell.net.