WASHINGTON & CHICAGO--(BUSINESS WIRE)--The Alliance for the Adoption of Innovations in Medicine (Aimed Alliance) — a non-profit organization working to expand patient access to effective treatments and technologies — today said trial attorneys should help consumers challenge unethical, inefficient, and, in some cases, illegal insurance practices that require high out-of-pocket payments, delay access to treatments, and interfere with the relationship between the patients and their health care practitioners.
This call to action is the subject of Aimed Alliance’s scholarly article entitled, “Now or Never: The Urgent Need for Action Against Unfair Coverage Denials for Quality Health Care,” to be published in June in the upcoming edition of the Loyola University Chicago Law Journal. Aimed Alliance’s Executive Director, Stacey L. Worthy, will speak on this topic at “Voices of Value: Spotlight on Rare Cancers, Orphan Drugs and Why Patients Need AIR,” hosted by Patients Rising on Sunday, June 4, 2017, concurrent with the global cancer conference meeting in Chicago.
“Individuals who are denied access to treatment may have legal remedies available to them,” said Ms. Worthy. “That’s why we’re calling on trial attorneys to get involved — to take initiative by offering a public-good in fighting insurers who have broken laws, and in assisting patients to get the coverage they deserve.”
The paper cites insurance practices, such as step therapy policies that require patients to fail on cheaper treatments, sometimes with harmful side effects, before patients can access the treatment that was prescribed. The paper notes, “In reality, step therapy policies can be cruel and unethical” and highlights laws that may protect patients from such policies. For example, if step therapy prevents a health care practitioner from prescribing the treatment he or she believes is best for a particular patient, the practitioner could sue for interference with the physician-patient relationship. And if the insurer fails to disclose its step therapy policy to enrollees in its plan, then that could be considered deceptive and misleading in violation of the state’s unfair trade practice act.
Other practices cited in the paper will include:
- Burdensome requirements for prior authorization that can delay treatments for patients who are too ill to have time to spare;
- Adverse tiering that requires the highest level of out-of-pocket cost sharing for medications that treat a serious, life-threatening illness;
- Inadequate networks that lack a sufficient number of health care providers or contain misinformation about whether a practitioner is in-network; and
- Clinical pathway programs that give practitioners financial incentive (or disincentive) regarding prescribing certain treatments, creating an unethical conflict of interest.
“I’ve personally experienced hardship at the hands of health insurance,” says Marcus Davis, an attorney in the Atlanta area. “When I was diagnosed with a cancer called smoldering myeloma, my insurance company told me they would not pay for any medical costs associated with the clinical trial I entered to get the latest treatments. What was I to do – forgo treatment or bankrupt my family with enormous medical expenses?”
Mr. Davis adds, “When I learned that the company had signed the Georgia Cancer Coalition Agreement, requiring them to pay incidental costs of clinical trials, I confronted them and the company rescinded their written denial of coverage. Four years since diagnosis, I enjoy a complete response. I’m not sure that would be true if I had just accepted the insurance denial and forgone treatment to spare my family financial ruin. I suspect many unsuspecting patients do just that, and I am grateful for what Aimed Alliance is doing.”
The paper is the latest effort from Aimed Alliance’s Know Your Health Insurance Rights Campaign. The Campaign encourages consumers to appeal coverage denials by providing them state-by-state information on filing appeals and complaints. However, if appeals and complaints are unsuccessful, a lawsuit is the next step.
“Through complaints and lawsuits we can identify patterns and practices of bad behavior among certain insurers,” said Ms. Worthy. “By taking action, we can effectuate a meaningful change and help individuals get the treatments they need.”
About The Alliance for the Adoption of Innovations in Medicine (Aimed Alliance)
Established in 2013 and based in Washington, DC, the Alliance for Adoption of Innovations in Medicine (Aimed Alliance) is a tax-exempt, not-for-profit organization that seeks to improve health care in the United States through access to evidence-based treatments and technologies. Aimed Alliance’s supporters are disclosed at http://www.aimedalliance.org/collaborators/.