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

Step therapy aims to cut expenses for insurance companies, but the cost to patients with skin conditions is just too high.

Forgo medication or sacrifice everyday essentials? Co-pay accumulator adjustment programs force patients to make difficult decisions about their health.

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

When insurers require that patients "fail first" before accessing their prescribed treatment, patients can suffer.

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.

Patients with chronic or serious medical conditions must sometimes work with physicians for months to identify a medication that’s effective for them.

Q: How do you explain co-pay accumulator programs to people?

A: Here we are talking about a program that impacts patients who use a manufacturer- provided card to help cover their co-pay. Co-pay accumulator programs are not as familiar a concept as, say, prior authorization or step therapy.

Q: What’s the best way to explain prior authorization?

A: It’s best understood in layman’s terms. If I ask a group of patients if they’ve had any issues with prior authorization, no one will raise their hand. But when I break it down and ask if anyone has had to prove to their health plan that they need a medication, heads start nodding. Hands shoot up.

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Q. “Non-medical switching” is an unfamiliar term to many. How do you explain it?

The term “non-medical switching” can be confusing, but everyone knows someone with a chronic health condition. So I frame it in those terms. I explain that the goal is to protect patients’ access to medications that keep them stable, that it’s senseless to take away a treatment that’s working. People seem to understand that intuitively

Q. What’s the best way to define step therapy?

I have found people respond better to the term “fail first.” It’s more intuitive for patients. When they hear “fail first,” it clicks with them that they are being forced by their insurer to try a different medication and only get the one they were prescribed if the first “fails” to help.

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Sometimes, getting the medication your doctor prescribes can be very complicated. That may be due to insurance policies such as step therapy. 

Also known as “fail first,” step therapy requires patients to take other medications and fail on them before the health insurer will pay for the medication originally prescribed by their doctor. 

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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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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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