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Insurers' exclusion of disease treatments increases costs

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The two largest providers of prescription medication programs have nearly tripled the number of medications that insurance companies will no longer cover, according to a new study by the Doctor-Patient Rights Project. (AP Photo/Rich Pedroncelli, File)

Every year, hundreds of thousands of patients with chronic illnesses are forced to switch from their prescribed treatments to medications their health insurance provider decides it prefers.

Some patients refuse to change medicines every time their insurer shifts coverage. Instead, they pay out-of-pocket and either skip doses or cut pills in half to make their original prescriptions last longer. Coverage changes that compel patients to reduce adherence to medication protocols make treatment less effective and ultimately increase the cost of patient care.

Most health insurers outsource their prescription medicine programs to pharmacy benefit managers, PBMs. Since 2014, the nation’s two largest PBMs — CVS and Express Scripts — have nearly tripled the number of medications that the insurance companies will no longer cover, according to a new study by the Doctor-Patient Rights Project, DPRP. By far, the largest group of excluded medications are treatments for chronic illnesses — conditions that develop over time, generally have no cure and require lifelong treatment.

Treatments for diabetes, for example, represented between 18 and 26 percent of all formulary exclusions over the past four years. During that time, moreover, the total number of diabetes-related treatments the PBMs won’t cover has increased by nearly 80 percent.

Over time, the PBMs have also steadily increased the number of treatments for chronic pain and inflammation that they exclude from coverage. In 2014, when both PBMs first started issuing formulary exclusion lists, they only excluded two chronic pain medications between them. Their 2018 lists, however, include a combined 12 different chronic pain and inflammation medications they will not cover.

DPRP’s study documents how some patients will reduce or discontinue treatment if faced with higher out-of-pocket costs for the medication their doctor originally prescribed. When some of the poorest and most vulnerable patients suddenly find that their insurance company will no longer cover the drug they have been taking for years, many choose to stretch their original prescriptions by taking smaller doses or taking them less frequently rather than switching to the PBM’s preferred alternative.

For patients treating chronic pain, who have kept their suffering at bay with one tried and true medication, it is easy to see why they would break from the prescribed treatment regimen rather than switch to a new treatment, even if it is cheaper.

The DPRP study found that many of the patients that may simply stop taking their prescribed treatment rather than switching to the PBM’s alternative are those who do not feel the symptoms of their chronic conditions, like patients with high blood pressure who do not experience chest pains immediately upon reducing dosage or discontinuing treatment.

By the time these patients start experiencing symptoms, however, their chronic diseases may have progressed, leaving them at further risk of complications that require additional medical care or even hospitalization.

Worse yet, if patients with an autoimmune disease like rheumatoid arthritis are taking an oral pill medication once a day, and CVS’s formulary exclusion list forces them to switch to a medicine they have to inject themselves, they will almost certainly cease to adhere to proper protocols for the medicine, leading to significantly worse health outcomes. According to DPRP’s study, reduced adherence to medication protocols is responsible for as many as 10 percent of hospitalizations and 25 percent of nursing home admissions, and may cause as many as 125,000 deaths each year.

Even if only a committed minority of patients treating chronic diseases ends up reducing adherence to their originally prescribed treatments (or discontinuing treatment altogether), the additional medical costs that result from letting their conditions progress more than exceed the savings insurance companies accrue by forcing patients to switch to cheaper medications. By some estimates, treatment nonadherence costs the U.S. healthcare system as much as $289 billion each year.

Ultimately, however, it is not the expensive cost of medical care that should make insurers think twice about excluding treatments for chronic illness from their formularies. The deeper issue is that no patient should be made to suffer from a condition that can be effectively treated just so insurance companies can increase their annual earnings.

Seth Ginsberg is president and co-founder of Global Healthy Living Foundation, and a founding member of the Doctor-Patient Rights Project.

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