President Trump’s latest executive order expands the number of cheaper, temporary health plans patients typically use to maintain continuous coverage. Trump claims it will allow “millions and millions” of Americans to afford health insurance. But the President overlooks that even patients with higher quality plans are routinely denied coverage for treatments prescribed by their doctors.
Among other things, Trump’s executive order expands the number of plans that are intended to provide a bridge for patients transitioning between more comprehensive coverage. Obamacare waived the requirement that these bridge plans cover ten essential healthcare benefits, but only for three months. Trump’s order would extend the waiver so that patients could stay on the plans up to a year.
Despite Obamacare’s requirement that health plans cover ten essential benefits, insurers may deny one-in-four insured Americans — as many as 53 million patients — treatment coverage for a chronic or persistent illness, according to a recent survey commissioned by the Doctor-Patient Rights Project. Of the patients denied coverage, moreover, more than a third will have to go without treatment because they cannot afford the cost on their own.
At least 63 percent of the patients denied treatment coverage that DPRP surveyed reported the denial was due to one of several “utilization management” protocols that insurers employ to influence patient care decisions and manage total healthcare costs. While UM protocols can help limit side effects from cutting-edge medications and manage unnecessary costs, when applied too aggressively, they can block patients from accessing needed care.
Perhaps the best-known UM protocol is the “prior authorization” requirement, which forces doctors to obtain approval before prescribing a specific treatment. Between 12 percent and 36 percent of all patients denied treatment coverage DPRP surveyed said that prior authorization was the reason they were denied. Moreover, most reported that it took a month to get a decision for their insurer. For 28 percent, the process took three months or longer.
For patients treating chronic conditions, waiting three months to receive effective treatment allows their disease to develop, increasing symptoms, decreasing health and making treatment more difficult and expensive, if and when it the insurer approves coverage.
“Step therapy” is another UM protocol patients may know better as “fail first.” Under this protocol, insurance providers refuse to cover a doctor’s prescribed treatment unless the patient documents that each of the medicines in the insurer’s preferred sequence proved ineffective.
Doctors prescribe precise treatments for a reason, and generally after considering a patient’s medical history and unique physiology. Step therapy views all patients treating a particular illness the same and demands that patients prove their difference by trial-and-error with the insurer’s chosen treatments. At best, step therapy second-guesses the doctor and delays effective treatment. At worst, it exposes patients to unexpected complications and potential adverse reactions.
A study in the American Journal of Managed Care found that the initial reductions step therapy causes in pharmaceutical costs are overwhelmed by more than $99 per patient in additional emergency room visits and in-patient hospital stays.
One UM protocol gaining favor recently is “formulary exclusion.” Insurers typically release — usually through their pharmaceutical benefit managers — annual formularies, lists of the medicines, procedures and supplies the insurer will cover, and at what level. About five years ago, however, insurers started also issuing lists of the treatments they explicitly would not cover, without an arduous appeal by a patient and the treating physician.
Since 2014, the number of treatments announced on the formulary exclusion list of America’s second largest PBM — CVS Caremark — more than quadrupled. The number of treatments excluded under the list the nation’s largest PBM — Express Scripts — nearly tripled. Insurers claim only a tiny percent of current enrollees are affected by formulary exclusions. Yet, formulary exclusions were by far the most common reported justification insurers gave for denying treatment coverage, according to DPRP’s recent survey.
Health insurance is supposed to facilitate patient care, not stand in its way, overruling physicians and dictating treatment decisions. By focusing on the quantity of people who would be covered under his order, Trump overlooks the quality of that coverage, and provides little help for the “millions and millions” who would be subjected to insurers who overzealously impose UM protocols and block patient access to care.
Seth Ginsberg is President and Co-Founder of the Global Healthy Living Foundation, a founding member of the Doctor-Patient Rights Project.
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