Pharmaceutical Sticker Shock

With the entire country struggling to come to terms with the rising cost of healthcare, insurers are increasingly choosing the easy way out – making the sickest patients shoulder more of the cost for specialty drugs.

Chronic ailments are undeniably expensive. Conditions like rheumatoid arthritis, AIDS, and cancer account for a big chunk of prescription drug costs. Until recently, insured patients paid a co-pay like everyone else, regardless of medical needs. The insurers including the biggest names in the industry began to re-categorize drugs into more expensive tiers, leaving patients holding the bag. The price hikes are no joke. Some Anthem Blue Cross Aids patients saw their costs increase to five times the previous amount beginning early this year. Company spokesperson Darrel Ng puts a high-gloss spin on the move, calling it a shift from “a co-pay tier to a cost-sharing tier” to “to enhance value and affordability.” For whom?

The four tier plan adopted by many insurers starts with a $10 co-pay for generic drugs, with a $30 co-pay for preferred brand-name drugs, a $50 co-pay for non-preferred brand-name drugs, and a top tier of specialty drugs with either a $150 co-pay or a 10% to 30% co-insurance cost – which in some cases is astronomical. Today, the 4-tiered plan is in use for 14% of insured workers, double the number from just five years ago.

The danger here is obvious. People who can’t afford medicines for life-threatening conditions won’t take them…and will wind up in even more expensive health crises down the line. On the up side – for the insurance companies – people who don’t take their prescribed medications are likely to live shorter lives.

Twenty states have pending legislation to cap out-of-pocket expenses, but insurance companies are, unsurprisingly, fighting the push. They argue that caps would raise premiums for all insurers and would be redundant, since the Affordable Care Act establishes out-of-pocket cost caps starting in 2014.

There are a number of issues at stake. Someone has to bear the brunt of the cost, and none of the options are good. The insurance companies are not going to pay the cost, and it’s not fair to ask employers to do so. But patients already face hefty costs. Consumers are likely to push back if shared cost is proposed, and politicians are certain to use that scenario to score points. If these drugs represent a Hail-Mary, end-of-life pass, perhaps a more restrained approach is acceptable, but many of these drugs are for chronic conditions people may live with for a very long time.

What’s the answer? Could the cost be shared all the way up and down the line, from manufacturer to all insured? That might be the most compassionate and cost-effective way to manage patient costs, but it is sure to engender controversy. How else could costs be alleviated?