In 2013, Ms. Potter noted, 17% of employers offered high-deductible health plans as their employees’ only option—up 31% from 2012, according to PricewaterhouseCoopers’ “Behind the Numbers 2014.” For 2014, she said, some 44% of employers were considering such a move (http://pwc.to/​1eRYLxr).

High-deductible plans can pose challenges for anyone with a chronic condition, but they are particularly problematic for patients taking expensive specialty medications, with annual minimum deductibles of $1,250 per person and $2,500 per family. The 2014 annual cap on out-of-pocket costs is $6,350 for an individual and $12,700 for a family—high for anyone, but harder to swallow if it’s front-loaded into the first month or two of each year because of costly specialty drugs.

Those steep costs can be a powerful trigger for noncompliance. In one study, high-deductible health plans were found to reduce adherence to prescription medication regimens in four of five conditions evaluated: hypertension, dyslipidemia, diabetes and depression (Am J Managed Care 2013;19:e400-e407), Ms. Potter noted. Only in asthma/chronic obstructive pulmonary disease was there not a significant decline in adherence.

The conditions included in the compliance study generally do not require specialty medications, Ms. Potter pointed out; it’s thus possible that the documented adherence problems might be even more pronounced when it comes to specialty medications, “particularly because few of these drugs have generic alternatives in a lower tier, and patients may have to pay $7,600 or more per year out of pocket for specialty medications,” she said.

Health Exchanges Not Immune

If employer-sponsored plans are increasingly moving toward high deductibles, many plans on the new health insurance exchanges—especially at the lower bronze “metal level”—are already there. In December, HealthPocket Inc., which compares health insurance plans for consumers, found that the average annual individual deductible for a bronze plan was just over $5,000, in addition to the average premium of $295.51 a month, or $3,546 a year (http://bit.ly/​1oevFqq).

“These high-deductible plans are causing a bit of a problem,” Debbie Stern, president of Rxperts, told Specialty Pharmacy Continuum. “It’s really putting a high burden on the patient to come up with all of that up front. Even if it’s just a $2,000 deductible, the patient has to pay that up front almost immediately for most specialty drugs, so the first prescription is going to cost them almost the full out-of-pocket for the year. When these plans were designed, people were thinking of drugs that cost $200 a month, not specialty drugs that cost $2,000 a month or more.”

Here’s where good specialty pharmacies can really distinguish themselves, Ms. Potter said. “You can provide additional patient support, working proactively to help patients understand their medical plans and anticipate their financial demands.” (See sidebar for more details on these strategies.)

That’s already happening at many specialty pharmacies around the country, according to Kyle Skiermont, PharmD, the director of specialty/infusion operations at Fairview Pharmacy Services in Minneapolis. “We’re seeing a big increase in high-deductible plans, along with a rise of coinsurance,” Dr. Skiermont said. “We’re seeing both more patients with these plans, as well as higher dollar amounts they’re needing.”

Fairview has doubled its staff of patient financial advocates over the past year to help address the growing need. And it’s not just that more patients need assistance—their situations are also becoming more and more complicated, Dr. Skiermont noted. “Where one advocate might have been able to handle many more patients in the past,” he said, “each patient we are helping is taking more time and getting more complex in [his or her] needs.”

Many of the foundations and other sources of funding for medication assistance are also getting tapped out more quickly. That, too, requires creativity. “Some foundations recharge their funds over the year, so if you ask for a grant on behalf of your patient and it’s not there, you need to know when to go back to them,” Dr. Skiermont said. “Maybe there was no funding in March but there may be in October. It requires a lot more interaction and advocacy for our patients, multiple times a year, whereas historically we might have only needed to do that once a year.”

“We’ve been getting more and more creative around what we can do as far as payment plans,” Dr. Skiermont added. “If we know someone has a big out-of-pocket maximum that they’re going to hit in the first month, we’ll try to make arrangements to pay that over the year.”

It’s a patchwork solution that likely is not sustainable in the long term. “In the short term, we feel we owe this to our patients. As a nonprofit, health-system–based specialty pharmacy, providing this kind of high-touch financial assistance is one of our differentiators.

It’s core to our mission,” Dr. Skiermont said. “We need to continue to be innovative and make this work for our patients, but ultimately something is going to have to change. A lot of the burden is falling on specialty pharmacy, but at the same time, the providers and the pharmaceutical companies are beginning to understand the coverage issues better than they did a couple of years ago, and are helping us bring the message to the patient. The reality is that everyone’s still trying to figure this out.”

by Gina Shaw

At least five states have enacted laws limiting copays and two — New York and Alaska — have expressly prohibited the use of tiered formularies for specialty medications. Another 11 states, including California, Illinois and Virginia, have legislation up for consideration that would limit copays.

That state governments are stepping in to place limits on cost-sharing for specialty drugs suggests that public angst over rising out-of-pocket costs is reaching an inflection point—monthly drug costs that were once affordable for patients with conditions like arthritis or multiple sclerosis are becoming harder to cover as part of a family budget. Consumers are seeking relief and lawmakers are turning to insurers to limit what they can charge their members.

“The trend towards increased reliance on specialty pharmaceuticals would not raise such an important concern if specialty drugs did not represent the most expensive segment of pharmaceuticals not only for insurers, but also for consumers through cost-sharing measures,” as Chad Brooker, a health policy analyst at Connecticut’s insurance exchange, Access Health, wrote in Health Law and Policy Brief last year.

By some estimates, specialty medications account for only one percent of all U.S. prescriptions but 25 percent of national drug spending. Not only is that set to grow to as much as 45 percent by 2017, but the assumption that prices for existing will fall over time may not always be the norm.

Teva Pharmaceuticals’ Copaxone, an injection-based multiple sclerosis drug, debuted in 1996 at a price of about $1,000 per month, by 2008 was priced at $2,000 per month, and nowadays is hovering around $5,000. To continue reading click here.

By:  Anthony Brino

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Meanwhile, the pharmaceutical industry is trying to derail a vital federal drug discount program called 340B that helps hospitals and community health centers supply lower-cost medicines and enhanced services to underserved patients.

The industry’s profiteering has gotten the attention of Congress, insurance companies and patients. Per-unit costs on specialty drugs rose 12 percent last year, according to Express Scripts. A database compiled by Bloomberg News shows the steady price increases of leading medications during the past seven years. An Epipen for allergic reactions rose 222 percent. A single dose of the drug Benicar for high blood pressure is up 164 percent. The high-cholesterol medicine Crestor jumped 103 percent per pill.

Against this backdrop, the drug industry has marshalled an army of lobbyists to go to war against poor, underserved Americans and the hospitals that treat them. Congress created the 340B drug discount program in 1992 with bipartisan support to allow health providers that serve large numbers of low-income patients to receive discounted medication from drug companies. In turn, these safety-net hospitals and clinics supply low-cost or no-cost medicines to the community. The program also helps fund diabetes, HIV/AIDS, cancer, dental and primary-care clinics.

Affordable medications are the key to improving health outcomes. When drug costs get too high, patients skip doses — or pass up buying prescriptions altogether. According to a survey from the Commonwealth Fund, the United States leads the world in this respect, with one quarter of adults choosing to go without their medications. Their health often declines and many end up back in the emergency room, largely on the taxpayer’s dime.

Everyone agrees, even John Castellani, CEO of the industry trade association PhRMA. In a recent interview with Kaiser Health News, he said patients’ “out-of-pocket expenses are potentially so high that we have to be concerned about whether or not people will be able to afford to continue to get their medicines.”

In fairness, Castellani was complaining about high prescription deductibles in some plans offered under the Affordable Care Act. But what about the devastating impact of his own industry’s overpriced medications? Here, Big Pharma ducks responsibility and conveniently chooses profits over people.

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• by: GIL GUTKNECHT

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