WASHINGTON, D.C. & SACRAMENTO, Calif.--(BUSINESS WIRE)--The Alliance for the Adoption of Innovations in Medicine (Aimed Alliance), a not-for-profit organization seeking to improve healthcare in the US, said many of the barriers to treatment that prevent patients from receiving quality care as prescribed by their physicians, may be discriminatory cost-saving measures proscribed by current law. Stacey L. Worthy, Director of Public Policy at the Aimed Alliance, was critical of insurance practices that create and impose these barriers, including:
•Fail first policies in which patients are required to fail on older, inferior treatment before getting the treatment their doctors prescribed;
•Adverse tiering in which most, if not all, medications, including generics, used to treat a condition, such as HIV or Hep C, are placed on the highest cost-sharing tier in which up to 50% of costs are passed on to the patient;
•Clinical pathways in which an insurer pays a practitioner to prescribe a cheaper medicine despite the patient’s needs;
•Prior Authorization in which practitioners can spend up to 20 hours a week on the phone with insurers trying to obtain approval for treatment they’ve prescribed for their patients; and
•Nonmedical switching in which insurers are forcing stable patients to switch to different cheaper medications without even informing the patients’ doctor.
Speaking at a forum and webcast in Sacramento arranged by the advocacy organization PATIENTS RISING, Ms. Worthy said, “These practices serve to financially exclude patients with a pre-existing condition, create a blatant conflict of interest for the physician, take up valuable physician time trying to obtain approval for the treatments, and in the end, just serve to save company money.”
Ms. Worthy added, “Fortunately, there is much that can be done to blunt these practices. Just using California as an example, we see many legal and legislative options for patients.”
Legislative and Legal Options
California passed a wide-reaching step therapy bill in October 2015 that allows practitioners to bypass step therapy when they determine an older treatment would be medically inappropriate for the patient. California also became the first state to cap monthly copays for specialty drugs on state health insurance exchanges. Furthermore, California has joined 39 other jurisdictions in requiring equal reimbursement rates for cancer medications whether taken by mouth or through a needle in the arm.
In addition, the Aimed Alliance says many barriers to treatment reimbursement may violate the nondiscrimination provision of the Affordable Care Act (ACA), commonly referred to as Obamacare. Other practices may also be illegal when they exclude patients, delay coverage, provide a conflict of interest, or otherwise save insurance money at the patient’s expense.
For example, last year, California investigated Health Net for using bait-and-switch tactics to enroll Californians into inferior health plans under the ACA. California regulators ordered Blue Shield of California and Anthem Blue Cross to repay millions of dollars in refunds to patients who unknowingly went out of the approved network of physicians for their care. Additionally, Anthem Blue Cross was ordered to refund $8 million to Californians because it had made mid-year changes to consumers’ annual deductibles, co-pays, and other out-of-pocket costs, and the company is currently facing a class action lawsuit for refusing to provide coverage of a hepatitis C cure unless patients had advanced liver damage.
“We’re pleased that Stacey Worthy and the Aimed Alliance brought these issues to light at our forum in California,” said Jonathan Wilcox, Policy Director for Patients Rising. “This comes at a critical time when an insurance-backed think tank, ICER, The Institute for Clinical and Economic Review, is proposing ‘value frameworks’ that rate cancer therapies against an arbitrary and often irrelevant monetary benchmark.”
Ms. Worthy said, “Such a framework could be used by insurers and pharmacy benefit managers as an excuse to justify discriminatory cost-containment measures, while doing nothing to save money for patients, their families, or the healthcare system.”
Aimed Alliance is a tax-exempt, not-for-profit organization that seeks to improve health care in the United States by supporting the development of and access to novel, evidence-based treatments and technologies. For more information, visit www.aimedalliance.org and follow @AdoptInnovation on Twitter.