Restrictive Insurance Policies That Punish Patients
Michael D. Shaw says that insurance companies and pharmacy benefit managers are enforcing restrictive insurance policies that unfairly punish patients.
He highlights five recent findings from Alliance for the Adoption of Innovations in Medicine:
- Insurers continue to adopt policies that reduce options for therapies, resulting in patients not always getting the most effective—or correct—treatments physicians recommend.
- These actions by insurers and PBMs can jeopardize the health of patients nationwide.
- Patients now have greater out-of-pocket expenses because of these decisions, sometimes pricing them out of the medical treatment they need.
- Patients, in direct consultation with their respective doctors, should be making these decisions, not insurance company bureaucrats.
- These policies are seemingly arbitrary; excluding certain drugs, while ignoring breakthrough medicines.
“We must fix this problem by, first, acknowledging the gravity of this situation; and secondly, educating the public about the costs of inaction, as well as the denial of potentially lifesaving medication,” Shaw writes in a piece published at the Huffington Post. “The stakes are too high—and the risks are too great—for the current system to remain in place. When a new drug has a 1 in 5,000 chance to make it to approval, something is clearly amiss!”
Campaign 2016: Hillary vs. Patients
Hillary Clinton may have secured the Democratic nomination for president, but patients should feel insecure about her ideas for the future of health care. Morning Consult reports that Clinton supports “in principle” Medicare’s plan to slash reimbursement rates, which could drastically harm patients access to care.
“I think it is fair to say that she embraces the notion that CMS should find much better, more rational ways to pay for prescription drugs, and the incentives are flawed,” Chris Jennings, a Clinton health care adviser, said. “I think that she would hope that they not feel it necessary to walk away from their commitment in this area, but rather try to address legitimate constructive suggestions that have been made.”
In March, the obscure Centers for Medicare and Medicaid Services announced regulatory changes that are expected to have major implications for patients’ ability access life-saving treatments. The agency never bothered to consult patients before announcing the change.
Earlier this year, Grace-Marie Turner, president of the Galen Institute, cautioned that the changes deal a major blow to doctors and community clinics that already operate on “razor thin margins.”
“Since many community oncologists and physician practices are already operating on razor thin margins, this policy could mean that they could lose money every time they prescribe newer, more innovative therapies that they believe would be better for their patients,” she wrote earlier this year. “Further, this financial hit may cause some doctors and clinics to sell their practices to hospitals, where costs will be higher for both Medicare and beneficiaries.”
Jennings’ statement left open the possibility that Clinton might make minor amendments to the policy.
“There’s a big difference between stopping and just starting all over again, which I think she would say would be a mistake, and learning and applying constructive suggestions to improve the underlying concept,” he added.
The Looming Threat to Your Health
Our co-founder and policy director Jonathan Wilcox explains why value frameworks pose a looming threat to your health. In a recent post at our Patients Rising blog, Jonathan warns that such models leave patients without access to treatment.
“Once you reach a certain point in this analysis, the framework determines that you should be cut off from further treatment,” he writes. “It won’t matter what your doctors says or whether there’s a drug that could help you – if the formula says it’s too expensive, you’re done.”
He adds, “But what’s frightening to you and me is exciting for the health insurance industry and government regulators. They see value frameworks as a means of holding down health-care costs. If and when these value frameworks get implemented in health-insurance plans, they will likely lead to de facto price controls on medicines and treatments.”
Value frameworks forget what health-care is all about: the health and well-being of patients, especially those battling life-threatening illnesses.
Next Step: Insurance Approval
Right now, most patients who develop metastatic disease must rely on the incremental progress that’s being made in treatments. However, Avera Cancer Institute and the Center for Medicine in the Public Interest have reason to believe that sequencing-guided treatments for patients with advanced malignancies could trade incremental gains for breakthroughs in treatments.
In an abstract at the American Society of Clinical Oncology’s 2016 annual meeting in Chicago, Avera Cancer Institute and the Center for Medicine in the Public Interest shared their research on treatments “based upon computational analysis of multi-platform molecular data, tailored for each patient based upon their past medical history, performance status and unique molecular profile, and curated to prevent the development of resistance.”
“We hypothesized that genomic and proteomic profiling of samples from advanced patients would identify genomic alterations that are linked to targeted therapies, and that this could facilitate a personalized approach to therapy for our patients,” the group’s noted in their presentation at ASCO 2016. “Our remarkable initial data provides very strong evidence that it is critical to incorporate multi-platform profiling as early as possible (preferably at diagnosis) in the disease course to allow for the best chance of benefit.”
The next step will be to work with insurance companies “to grant approval for off-label treatments/combinations.”
