Many patients with chronic and complex illnesses can stabilize their conditions and resume normal lives with the help of advanced medical therapies. But finding the right therapy often takes physicians and their patients through a painstaking process of trial and error, which can drag on for months or even years. For these patients, medical stability is hard won. Yet insurers sometime opt to sacrifice patients’ stability by imposing non-medical switching, compelling patients to abandon an effective therapy for a less costly alternative—for reasons unrelated to patients’ well-being.
Restricting non-medical switching can protect not only patient health but also the physician-patient relationship’s role in guiding patient care. Issue advocacy and education can raise awareness about the importance of patient access to approved medical therapies and galvanize support for legislation that limits such practices.
If a patient’s condition is stabilized on their current therapy then they have a right to stay on the medicine their doctor has prescribed. This right should persist from plan year to plan year, and continue even if the health plan drops the medicine from its formulary. Only with the patient’s and doctor’s consent should a health plan or a pharmacy be able to switch a patient to a different therapy.
Content created by Keep My Rx.
Patients with chronic and complex diseases often require medication so they can do their jobs, care for their families and participate in their communities. But increasingly, cost-focused insurers are forcing patients to abandon proven treatments for cheaper alternatives, what’s known as “non-medical switching”.
Asthma’s prevalence has more than doubled in recent decades, yet the disease remains highly individualized. Patients’ triggers, the severity of their symptoms, their ability to manage their condition, and their success with different treatments and delivery mechanisms varies.
While clinicians recognize this fact, health plans may not. Insurance coverage models too often embrace a one-size-fits-all approach that generalizes care based on rigid disease-state algorithms that prioritize the lowest-priced treatment options. The approach incorrectly assumes that patients are interchangeable, and that children are just small adults.
Increasingly, insurance companies and even pharmacies may drive changes in asthma medication or delivery device that are unnecessary, expensive and even dangerous for patients.
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.
What happens when patients’ medications are switched for financial reasons instead of medical reasons? Does it affect their health? Their course of care? The overall cost of treating their condition?
Almost 1 in 10 Americans – men, women, and children of all ethnicities and income levels – has diabetes. One of the most common medical conditions in America, diabetes has become more widespread in recent years, increasing by more 1 million people between 2012 and 2015 alone.
Not surprisingly, diabetes is an expensive disease. In 2017 diabetes cost the United States $237 billion in direct medical costs and $90 billion in reduced productivity, accounting for about one in every four health care dollars spent. People with diabetes incurred an average per-patient cost of $16,750 a year.
Diabetes’ impact and prevalence demand policies that allow people to access appropriate medications and effective health care.