Paying for Rheumatology Care is Complex

The price of a medication can be a significant factor in poor adherence to treatment, and few other specialties have higher medication prices than rheumatology. How can rheumatologists help their patients navigate the system so that they can get the best medication at the best price? 

In the current U.S. healthcare system, it can be difficult to determine exactly how much a drug will cost a patient in advance of receiving treatment. The Associated Press reported in August that nearly 40 percent of people who get their health insurance through an employer must pay at least part of cost of prescriptions, either through a copay or coinsurance. Patients with Medicare Part D may pay different prices for the same drug during the year because of the “donut hole,” where the plan first pays 25 percent of a drug’s cost, then none of it, and then 5 percent over the course of the year.

“Navigating the insurance landscape for expensive medications is incredibly complex,” says Colin C. Edgerton, M.D., chair of the Committee on the Rheumatologic Care of the American College of Rheumatologists. “Helping patients understand their benefits, and slogging through prior authorization requirements is specialized work, and most rheumatologists must allot paid staff time to these duties. Even with excellent staff, it is common for patients not to be able to obtain their prescribed medications.” 

A study published on September 10 in Arthritis Care and Research, found that prior authorizations were associated with treatment delays and denials and as a result, patients are increasingly using glucocorticoids to manage arthritic flares. “Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be re‐evaluated,” wrote the authors who were led by Zachary S. Wallace, M.D., MSc, Harvard Medical School, Boston.

Other studies have shown that some patients often have no real understanding of how their health insurance works, what it covers, or what terms like copay and coinsurance mean. The U.S. Department of Health and Human Services says that only about 12 percent of adults are proficient in health literacy, which is the percentage of people who can use a table and calculate a person’s share of health insurance costs for a year.

Under a new rule from Medicare, prescription plans must offer real-time pricing information (also called real time benefit checks) by 2021. This applies only to Medicare patients, but such systems frequently become available to everyone with a prescription plan once they are put in place. Several software companies are offering technology that provides real time benefit tools.
Some pharmacy benefit managers already offer real-time information that can help physicians and patients switch to a covered or lower-cost drug. But knowing how much the drug will cost in advance is no relief if that cost puts the patient into financial jeopardy or is out of reach completely.

In rheumatology, high-cost biologics may require more than one attempt to get approval from a health insurance company. Pharmacy benefit managers may require patients to fail first on less expensive medications or have tiered formularies.

“Due to the enormous out-of-pocket costs associated with even small percentage copays on the high-cost biologics, copay assistance programs are critical for patient access,” Dr. Edgerton says. 

Copay assistance programs are addressed in the ACR position statement “Programs Limiting Copay Assistance.” Finally, the issue of formularies exerting financial pressure on patients forcing switching from one agent to another are addressed in the ACR position paper “Therapeutic Substitution.”

“This is such a big problem that the ACR has dedicated several position statements to this,” Edgerton says. The position statements include “Drug Pricing,”“Access to Care,”“Patient Access to Biologics,” and “Step Edit Therapies.”

One of the goals of Rheumatic Disease Awareness Month is to help patients and their families become advocates about the disease and about the high costs for good rheumatology care.

REFERENCE:  HHS. “America's Health Literacy: Why We Need Accessible Health Information.”