[Ip-health] Concern Grows Over Cost of Drugs Under New Health Care Law - NYTimes.com

Claire Cassedy claire.cassedy at keionline.org
Tue Sep 17 14:04:17 PDT 2013


Concern Grows Over Cost of Drugs Under New Health Care Law

By Katie Thomas
Published: September 17, 2013

Among the most troubling questions facing consumers as they shop for
insurance under the Obama administration’s new health care law is whether
the plans will cover the drugs they take — and how much they will have to
pay for them.

But with less than two weeks remaining until enrollment opens on Oct. 1,
the answers are still elusive and anxiety is growing for consumers whose
well-being depends on expensive medications. States running the
marketplaces where the plans will be offered have not released details
about which drugs will be covered. Insurers have said little about how much
consumers will be asked to contribute or what types of restrictions will be
placed on certain medicines. Of the few states that have revealed
specifics, some plans will require patients to contribute as much as 50
percent of the cost of the most expensive drugs.

“I’ve got to be honest and say I’m a little bit nervous,” said Jessica
Thomas, a mental health counselor in North Carolina who takes the drug
Tecfidera to treat her multiple sclerosis.

Ms. Thomas, 34, has been enrolled for two years in a program for people
with expensive medical conditions that is run by the state of North
Carolina. But that program is ending in December, and she must select a new
plan in the state marketplace. At the top of mind for her is how much she
will have to pay for Tecfidera, which costs more than $4,000 a month. “I
think that’s the hard thing right now is that it’s the unknown, deciding
what the financial cost will be,” she said.

The picture will not get immediately clearer once enrollment begins.
Without a central hub for evaluating drug coverage, patient advocacy groups
say they are already warning their members to prepare for a tedious slog
through Web sites, downloaded records and phone calls to customer service
hot lines.

“I had frankly expected a higher level of transparency by this point,” said
Brian Rosen, the senior vice president for government and public affairs at
the Leukemia and Lymphoma Society.

Insurers and officials in the Obama administration are counseling patience,
saying that consumers will have six months, once enrollment opens, to
choose a plan that’s right for them. The administration asserts that
chronically ill patients are among the biggest beneficiaries of the new
law, given that insurers are now prevented from denying them coverage and
cannot charge them higher premiums because of their illness. “For many
Americans, these changes will mean that a diagnosis no longer means
choosing between facing bankruptcy or ignoring care,” said Erin Shields
Britt, a spokeswoman for the Department of Health and Human Services.

Others say some initial uncertainty and even confusion is to be expected.
“I think you have to walk before you can run,” said Karen Ignagni,
president and chief executive of America’s Health Insurance Plans, an
industry trade group. “This is a massive undertaking.”

The plans offered in the marketplaces must cover a minimum number of drugs
in every treatment category, with the exact count set by a representative
commercial plan, known as a benchmark plan, that is designated in each
state. Oregon, Virginia, Connecticut and other states plan to cover more
than 97 percent of drugs, while others like Maryland, Colorado and
California plan to cover from 54 to 84 percent, according to an analysis by
Avalere Health, a consulting firm. Patients can lobby for an exception if
they can demonstrate that a drug not covered by their plan is medically

But how many drugs will be offered under the plans is only a starting
point. Perhaps more significant is how much patients will be asked to
contribute toward the cost of those drugs. Only a handful of states have
released those details, but advocates for patients with chronic diseases
and those in the drug industry say they are troubled by what they have seen
so far.

Many of the plans are requiring that patients taking the most expensive
specialty drugs — those for treating serious illnesses like cancer,
multiple sclerosis and autoimmune disorders — contribute significantly to
the cost. For example, in Oregon, among the dozens of plans expected to be
offered are standard plans that will ask consumers to pay half the cost of
specialty drugs. Requiring consumers to share in the rising cost of
specialty drugs is not new, but Caroline Pearson, a vice president at
Avalere, said the practice appeared to be more prevalent in the plans
offered in the state marketplaces, and consumers will be asked to pay more.
A recent survey by the Kaiser Family Foundation of employer health plans
found that the current average contribution was 32 percent for specialty

The health care law limits the amount that a patient is required to pay out
of pocket to $6,350 a year for an individual and $12,700 for a family, a
welcome change for some patients previously required to pay tens of
thousands of dollars in drug and medical costs. Some patients will qualify
for subsidies that will further lower that cap, depending on their income,
and the cap applies to both medical and drug benefits.

Even so, Ms. Pearson said some patients may be asked to pay hundreds and,
in some cases, even thousands of dollars at their first visit to a pharmacy
once their plan goes into effect, a cost that could deny them needed

Jim and Joyce Boryska worry that they will quickly reach their limit
because Mr. Boryska, who has cancer, takes the drug Revlimid, which costs
more than $8,000 a month. Mr. Boryska left his job in construction after he
became ill and the family is covered under a continuation of his former
insurance. But that will end this year and they plan to sign up for
insurance in Oregon’s marketplace.

They still do not know if Revlimid will be covered by the plans offered in
Oregon, but if it is, it is typically considered a specialty drug. Under
their current plan, Mr. Boryska pays $100 a month for the drug. If they
choose a plan that requires significant cost-sharing, “this is not going to
be good for us, or good for any cancer patient,” Ms. Boryska said.

Damian Brayko, the operations manager at Cover Oregon, the state
marketplace, said the out-of-pocket limit acted as a powerful safety net
for patients with chronic illnesses. The health care law, he said, “isn’t a
perfect piece of legislation, but I think it’s taking steps in the right
direction, and that’s how we’re looking at it.”

Pharmaceutical companies have traditionally offered assistance programs and
coupon cards to help patients cover their out-of-pocket costs. But that is
another question that has not been answered yet. The Health and Human
Services department is still ruling on whether the state marketplaces could
be considered a federal program. Drug companies are prohibited from
providing direct assistance to recipients of Medicaid and Medicare because
it is considered an illegal kickback. Nonprofit groups that are often
financed by the drug industry provide assistance to those patients instead.

Many patient advocacy groups are questioning why the Obama administration
did not more closely adopt the features of Medicare’s drug benefits
program, known as Part D, which got off to a rocky start in 2006 but is now
seen as a successful program. One of the top features that advocates say
they wish was in the marketplaces is something similar to Part D’s Plan
Finder, which suggests plans based on the drugs that recipients take.

Ms. Ignagni, of the insurance association, said insurers were committed to
providing comprehensive information to patients, and added that was already
true today in the commercial marketplace. “We want to get information to
consumers, and that won’t change,” she said.

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