Patients are more than a number. But the QALY doesn't see them that way.

When insurers switch stable patients' medication, patients may face re-emerging symptoms, battle new side effects and even wind up in the ER.

When prior authorization delays treatment, patients can see their symptoms worsen and their relationship with their physician erode.

In a first-of-its-kind study, the Alliance for Patient Access reveals that non-medical switching, where insurers or pharmacy benefit managers drive stable patients to switch to lower-cost medicines, can levy widespread damage on patients’ quality of life.

It’s a familiar scenario for most of us. You get sick and go to the doctor. Your doctor takes your medical history, examines you, and makes recommendations about your treatment. Your doctor writes you a prescription. But, for many patients, the process of getting the medication prescribed by their doctor may be far more complicated.

A new trend has more health insurers implementing what are known as co-pay accumulator programs, which change how patients meet their annual deductible.  Insurers embrace the programs to increase their revenues and discourage the use of high-cost drugs.  But, in so doing, they leave patients with a difficult choice.

Pharmacy and therapeutics committees decide which medications will be used or covered by hospital systems, state Medicaid programs, insurers and federal agencies.

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Individual states sometimes establish prescription drug affordability review boards to explore ways to lower prescription medication costs for Medicaid patients and reduce the impact on the state health care budget. State legislators pass laws to create prescription drug affordability review boards.

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Patients who rely on prescription medication may encounter bureaucratic delays, high out-of-pocket costs or forced medication switching. These hurdles often stem from the work of middlemen known as pharmacy benefit managers.

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The Institute for Clinical and Economic Review is a health economics organization that assesses the value of new drugs, medical devices and diagnostics. Though ICER is not a government entity, its decisions often impact medication coverage by public and private health plans.

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What is the value of a new medication or medical device? The question is complex, and answers often vary depending upon who decides and which factors they prioritize.

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Co-pay accumulator adjustment programs are presenting patients with an ugly surprise at the pharmacy counter: The card that helps them afford their medication no longer counts toward their annual deductible. As more insurers and employees institute these programs, patients face serious consequences, including medication abandonment, financial hardship and non-medical switching. Ensuring patients’ access to their medication requires viable policy solutions.

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Patients pay premiums for their health insurance coverage but also have to bear other costs when they use that insurance. The additional costs patients pay for their medical services and prescription drugs break down into three broad categories.

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To get the medicine prescribed by their health care provider, patients must first prove that older, less expensive or insurer preferred alternatives don’t work. That’s the crux of step therapy, or “fail first.”

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For many patients with complex, chronic conditions, the process of identifying the right combination of medications takes considerable effort. Imagine then how patients feel when their insurance company forces them to change their medication on the basis of cost.

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Co-pay coupons are a common tool to help patients with chronic conditions cover the cost of expensive medications. Historically, co-pay coupons’ value has counted toward a patient’s annual deductible. Once the deductible is met, the patients pays a modest co-pay – a fixed amount – per prescription.

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Patients can be denied access to their medicine for days, even weeks because of a practice called “prior authorization.” It’s the process whereby insurance companies must approve a physician-prescribed medicine, procedure or test before a patient can get coverage.

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The story has become a familiar one. A patient with a chronic condition works with his or her doctor to find the right treatment. The condition is stabilized, manageable.

But then that stable patient is driven by the insurance company to a drug that’s less expensive. The switch prioritizes insurers’ profit over patients’ health. And it often comes with consequences: new side effects, re-emerging symptoms that had been under control, or interactions with medication the patient takes for other conditions.

Now, for the first time, a national study puts data points behind the story – providing a clear, measurable look at the qualitative impact of non-medical switching. This report details the findings of two in-person focus groups as well as a national poll of 800 patients who experienced non-medical switching firsthand.

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Not everyone can afford the medication they need. To make drugs more accessible, manufacturers sometimes provide co-pay coupons to help patients cover their out-ofpocket pharmacy expenses.

Manufacturers have issued co-pay coupons since the mid-2000s, but they have become more common in recent years. The amount of prescriptions paid for using coupons reached 19 percent in 2016.

Most drugs that have co-pay coupons don’t have lower-cost generic alternatives. For the few that do, these alternatives may not suit the unique characteristics of a patient’s medical history or disease state. Or, a patient has already tried the less expensive option and found it ineffective.

Regardless of what may be available, doctors should be trusted to prescribe the most appropriate medication for their individual patients. And when a doctor prescribes a costly regimen, until recently, patients could depend upon co-pay coupons to count toward their yearly out-of-pocket deductible. Many patients relied on this arrangement to access their medications.

Yet for patients across the country, that reality is changing.

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