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Editor's Note

New Tiered Copays Pricing Patients Out of Treatment

Fred M. Eckel, RPh, MS
Published Online: Tuesday, July 1, 2008   [ Request Print ]


Mr. Eckel is professor and director of the Office of Practice Development and Education at the School of Pharmacy, University of North Carolina at Chapel Hill.



The rising cost of monthly health insurance premiums has meant that many people cannot afford insurance. Now, even those with health insurance may not be able to afford some care.

The latest reason is a trend that is spreading rapidly among insurance companies. Many insurance plans are placing specialty drugs into new formulary tiers that shift a greater proportion of the drug's cost to patients. Patients who were previously charged fixed copayments now pay a share of the drug's cost, amounting to hundreds or even thousands of dollars per month. Formularies with these fourth and even fifth tiers are already typical among Part D plans, and recent reports indicate that they are rapidly being adopted by other plans too.

Some insurers say that this tiering makes patients more aware of the true cost of drugs and can encourage them to seek less expensive alternatives. In practice, this can be problematic. In many cases, no generic alternatives exist. Patients with chronic or acute conditions may have no choice but to pay up—if they can afford it.

Critics argue that this approach simply means shifting costs to patients and that these plans ultimately could be counterproductive, because they will cause patients to avoid or delay treatment, resulting in greater health care costs later on.

Whatever the intentions behind this change, it is clearly creating a problem. The underlying cause is the source of less agreement, however. Is it that drug manufacturers are pricing their products at what the market will bear? Or is it that intermediaries see opportunities to increase profits? For example, pharmacy benefit managers (PBMs), while claiming to save employers money, generate an increasing proportion of their revenue through specialty drug divisions. They have the potential to increase profits both by focusing on these expensive products and by imposing higher charges on those who have to pay for them. The question is whether the PBMs' lucrative business is to the benefit of the employers, who are experiencing rapid increases in specialty drug costs.

Whether this problem is due to specific players or is merely one indication of much bigger problems with the overall health care system, it is clear that change is needed.

That is one reason that this November's elections are so important. Your participation is critical: this is the time to study the issues and vote for what you want to see in our future health care system. Enormous pressure for change abounds. This is your chance to help determine the direction those changes will take.

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