Healthcare Reform Issues for Chronic and Rare Issues

THE PASSAGE OF a healthcare reform bill to increase benefits for the uninsured and underinsured still leaves unchanged issues faced by patients who have chronic and rare diseases and rely on expensive therapies. For these patients and their healthcare providers, the following concerns remain to be addressed in later legislation:

Unaffordable Copays/Coinsurance. Patients’ copays for their lifesaving therapies will increase, and many of these therapies will now fall under coinsurance that requires patients to pay 10 percent to 30 percent of the cost of the drug instead of a set amount. Because of this, patients will not be able to afford treatments.

Lifetime Caps. While these caps remain, it’s important that patients look at their insurance plan choices and know when they are going to reach their lifetime cap. When offered a choice between plans, such as HMOs and PPOs, patients sometimes have the option to switch during open season from one plan to the other, which could bring their lifetime cap expenses down to zero for that year. They can then switch back the next year to the preferred plan, again possibly zeroing out the expenses counted toward the lifetime cap. However, before making any changes, patients should first check with their insurance providers to determine whether making a switch would indeed affect their lifetime cap.

Step Therapy. To keep costs down, payers will require patients to undergo step therapy, even if it is contrary to their treating physician’s recommendation. To best defend against this strategy, patients must keep good notes, copies of lab work and medical journal articles that discuss the best treatments for their disease to be ready to appeal their insurance company’s denials.

Comparative Effectiveness versus Cost Effectiveness. Funding continues for comparative effectiveness research, which can determine health outcomes data on the best therapies for patients. If used correctly, comparative effectiveness can be a beneficial tool for patients. However, it depends on who is conducting the studies and for what reasons. For instance, comparing the long-term effects of intravenous immune globulin (IVIG) versus steroids for certain autoimmune diseases can help ensure coverage for patients and potentially result in new IVIG indications approved by the FDA.

Brand Switching. Payers are continuing to switch the type of prescriptions patients receive without prior knowledge of their physicians. This includes switching brand products to generics, as well as to different classes of drugs. In addition, patients who rely on plasma-derived therapies, such as IVIG and biologics, have been told their product is no longer available. In many cases, physicians are not aware of the change in product until patients have an adverse reaction. While the goal of payers is to save money, this practice puts patients’ health at risk.

Some of these issues need to be addressed on the federal level, while others need legislation at the state level. 2010 is the year for the plasma, biologics and vaccine communities to come together to ensure the voices of patients and providers are heard.