Specialty tier payments hurt patients [Commentary]

Health insurers in Maryland and throughout the country are jeopardizing patient health by dramatically and arbitrarily increasing the cost of vital medications. As insurers increasingly assign cancer treatments to so-called "specialty tier" cost structures, patients battling blood cancers and many other serious conditions are forced to pay prohibitively high out-of-pocket costs for their treatment, which causes many patients to go without treatment entirely.

Rather than paying a standard copayment for medication, people whose medications are moved to specialty tiers — which include the newest, most effective and expensive medications — can find themselves paying coinsurance of up to 40 percent of the total cost of the drugs. This can mean hundreds or even thousands of dollars in out-of-pocket costs every month for a single medication, exposing the patient to a significant financial hardship and, in some cases, an insurmountable barrier to care.

Many Maryland patients who obtain health insurance through the Maryland Health Benefit Exchange will also be affected, as many of the new insurance plans in the exchange also contain specialty tier cost structures that will mean high out-of-pocket costs for patients.

Although any patient might be affected by specialty tier cost increases, those patients most affected will likely be living with serious chronic and life-threatening conditions such as leukemia, lymphoma and other types of cancer, rheumatoid arthritis, hemophilia, multiple sclerosis, HIV, epilepsy, lupus and many others.

Perhaps just as disturbing as the discriminatory nature of specialty tier cost structures is the seeming arbitrariness with which insurers can change the amount a patient will have to pay for medication. A Maryland patient diagnosed with leukemia, for example, can select an insurance plan based on the cost of their specific medication but then have the insurer significantly increase the patient's financial responsibility for that medication by shifting the medication onto a specialty tier.

This breaks the central covenant of the citizen-health insurer relationship: Marylanders pay their monthly insurance premiums with the understanding that when they need medical attention — medicine or a test, for example — the health insurer will be there to share the financial burden. In the case of out-of-pocket cost increases, Marylanders are falling victim to an insurer bait-and-switch.

The financial burden of paying for prescription drugs, particularly in tough economic times, is a strain for many, but it has a potentially devastating impact for those patients living with chronic and life-threatening conditions. Dramatically increased copayments may jeopardize the financial solvency of entire families and jeopardize the ability of some patients to take their necessary medications. No one should have to choose between taking life-sustaining medication and paying rent or providing food for their children.

Arbitrarily driving up coinsurance costs for the most vulnerable patients undermines the basic premise of health insurance, which is to spread and share health care costs. Specialty tier cost structures do the exact opposite — they pass the financial burden of health care on to the most vulnerable patients, while the healthy and the health insurers pay less.

The Maryland legislature is currently considering common-sense patient protection legislation that would provide a small measure of relief to those Maryland families battling chronic and life-threatening conditions. Senate Bill 874 and House Bill 761 will increase access to medication by ensuring that the required copayment or coinsurance for specialty drugs does not exceed $150 per month for a 30 day supply.

The pending specialty tier legislation has broad patient and provider support, and we are pleased that the legislation is also supported by health insurer CareFirst BlueCrossBlueShield.

Treating cancer involves accessing a complex and extensive set of health care services including chemotherapy and prescription drugs, among others. All Marylanders battling cancer should have access to the life-saving medical care they need.

The Leukemia & Lymphoma Society urges legislators to put the interests of their constituents above insurer profits and support SB 874/HB 761.

Tracy Orwig is the director of patient access, education and advocacy for the Maryland Chapter of the Leukemia & Lymphoma Society, which advocates for the 2,530 blood cancer patients diagnosed in Maryland each year. Her email is Tracy.Orwig@lls.org.

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