New Tiered Copays Pricing Patients Out of Treatment

Pharmacy Times, Volume 0, 0

Mr. Eckel is professor and director ofthe Office of Practice Developmentand Education at the School ofPharmacy, University of North Carolinaat Chapel Hill.

The rising cost of monthly healthinsurance premiums has meantthat many people cannot affordinsurance. Now, even those with healthinsurancemay not be able to affordsome care.

The latest reason is a trend that isspreading rapidly among insurance companies.Many insurance plans are placingspecialty drugs into new formulary tiersthat shift a greater proportion of thedrug's cost to patients. Patients whowere previously charged fixed copaymentsnow pay a share of the drug's cost,amounting to hundreds or even thousandsof dollars per month. Formularieswith these fourth and even fifth tiers arealready typical among Part D plans, andrecent reports indicatethat they are rapidlybeing adoptedby other plans too.

Some insurers say that this tieringmakes patients more aware of the truecost of drugs and can encourage themto seek less expensive alternatives. Inpractice, this can be problematic. Inmany cases, no generic alternativesexist. Patientswith chronic or acuteconditions may have no choice but topay up—if they can afford it.

Critics argue that this approach simplymeans shifting costs to patients and thatthese plans ultimately could be counterproductive,because they will causepatientsto avoid or delay treatment,resultingin greater health care costslater on.

Whatever the intentions behind thischange, it is clearly creating a problem.The underlying cause is the source ofless agreement, however. Is it that drugmanufacturers are pricing their productsat what the market will bear? Or is itthat intermediaries see opportunities toincreaseprofits? For example, pharmacybenefit managers (PBMs), while claimingto save employers money, generate anincreasing proportion of their revenuethrough specialty drug divisions. Theyhave the potential to increase profitsboth by focusing on these expensiveproducts and by imposing higher chargeson those who have to pay for them.The question is whether the PBMs' lucrativebusiness is to the benefit of theemployers, who are experiencing rapidincreases in specialty drug costs.

Whether this problem is due to specificplayers or is merely one indication ofmuch bigger problems with the overallhealth care system, it is clear that changeis needed.

That is one reason that this November'selections are so important. Yourparticipation is critical: this is the time tostudy the issues and vote for what youwant to see in our future health caresystem. Enormous pressure for changeabounds. This is your chance to helpdetermine the direction those changeswill take.