Far too often, patients find themselves facing impossible hurdles to access something as simple as the treatments their doctors prescribe. Getting a life-saving medicine shouldn’t be an Olympic feat. But more often than not it is, and it’s no accident.
Heath insurers yield immense power and control when it comes to deciding what treatments patients can access. As a result, it’s health insurers versus patients and doctors in an epic battle – with patients crossing the finish line last, or not at all.
THE TEN TOP HEALTH INSURANCE COMPANY BARRIERS
Here are 10 of the most egregious health insurance company barriers that patients and providers experience every day (hyperlink to each section). We must eliminate them if we are to put decision making back in the hands of doctors and patients – where it belongs.
Step Therapy
Step therapy isn't a therapy at all. It is an insurance company tactic that often requires you to try one or more drugs before getting the medicine that your doctor prescribed.
Insurance companies use this with patients to maximize their profits. Here are few reasons why step therapy is harmful:
Medicine
It prevents the right medicine from getting to you at the right time.
Expertise
It limits the doctor’s decision-making ability.
Complications
It opens the possibility of otherwise preventable health complications.
Wasted Cost
It is highly inefficient and wastes money.
What can be done?
Health care decisions and insurance coverage policies should begin with a focus on improved patient health.
Step therapy should only be used if your doctor thinks it’s best. And when you encounter step therapy, it should be easy to work with an insurer to get the medicine you need.
If you have encountered step therapy, our patient guide can help answer questions about how to appeal decisions, work with doctors and insurance companies, and get the medication that was initially prescribed.
Prior Authorization
For patients who need immediate health care – or those who suffer from chronic conditions – the last thing they need to do is wait even longer to feel better or to manage their pain or condition. But that’s exactly what health insurance companies insist on by requiring patients to receive prior authorization for care options prescribed by their doctors.
Waiting is not just an annoyance. It can be a serious problem. Forty-five percent of providers surveyed reported that a patient’s care frequently had been compromised due to the time it took to receive prior authorization (1). It’s time to tell health insurers to let doctors and patients determine the best course of medical action.
Rebate Walls
Another health insurer barrier is the use of rebate walls in contracts, where the drug with the most profitable rebate return for the health insurer or Pharmacy Benefit Manager (PBM) is the drug that is accessible to patients, even if it’s not the one prescribed by their doctor.
Decisions shouldn’t be made on financial terms but that’s exactly what rebate walls do.
Non-Medical Switching
To control their costs and maximize their profits, health insurers issue non-medical advice to encourage patients to switch treatments – even if those treatments were prescribed by doctors. In one egregious example, a prominent health insurer offered patients a $500 debit card to encourage them to switch from one drug to another preferred drug even though the drug wasn’t subscribed by a physician. The same company followed up with a similar offer just weeks later.
Non-medical advice, paired with a financial incentive, undermines the vital patient/doctor relationship in determining what medicines and treatments are best for patients. It’s time to put patients first and preserve the patient/provider relationship for improved health and wellness.
High-deductible
health plans
A high-deductible health plan may offer lower monthly premiums, but enrollment means that the patient must pay more for their health care services before the insurance company will decide to cover costs. Some patients are forced to pay thousands of dollars out of pocket before their health insurance will cover anything at all. What’s worse – these out-of-pocket maximum limits are rising, making it harder and harder for patients to reach them. For rare and chronic conditions that require frequent or specialty treatments, a high-deductible health plan means the patient will be covering most of their own costs.
Similarly, insurance companies will advertise lower monthly premiums while hiding the poor benefit design of their plans, tricking patients into paying more than they should for healthcare. The language of these insurance policies is often confusing, leaving patients unaware of the benefits they may or may not be entitled to and putting up yet another barrier.
Denying Pharmacy of choice
Sometimes, insurance companies will require or financially steer patients to use a preferred or PBM-owned pharmacy instead of a community pharmacy a patient may favor. Half of PBM gross profits is estimated to come from mail and specialty pharmacy services (3).
While it’s about profit for insurance companies and PBMs, for patients, this means limiting their choice in where to go for their medications. As a result, patients face another barrier and may have a harder time accessing the insurance-approved pharmacy due to travel and time restrictions. Moreover, denying the use of certain pharmacies can also impact the important patient-pharmacist relationship that many patients rely on.
Copay accumulators
Copay accumulator programs are a tactic utilized by insurance companies and PBMs that allow these corporations to accept cost assistance without counting it toward a patient’s deductible. Many drug companies offer coupons and assistance programs to help cover the high costs of specialty drugs, but insurers only want to accept the patient’s own money toward meeting their out-of-pocket limits.
Copay accumulators allow insurance companies and PBMs to essentially charge twice for the same thing, leaving patients to pay increasingly more money for necessary treatments. It’s yet another example of patients facing barriers to accessing treatments while large corporations benefit financially.
Not Sharing Discounts
Insurance companies and PBMs regularly negotiate with drug manufacturers to get better rates. Ideally, these rebates and discounts would be passed along to the consumers. Instead, the middlemen corporations collect large rebates from pharmaceutical companies, often based on the list price of a medicine, which leads to higher prices and favoring care options based on the rebate instead of clinical benefit (4).
Rebates and discounts are designed to help patients, but insurers and PBMs won’t share the savings, which would help patients at the pharmacy counter. This leads to another barrier between patients and life-saving treatments and care options.
Complex Appeals Process
In some cases, patient claims will be denied by their insurer, meaning the insurance company has simply said “no” to covering a treatment or service. In this situation, patients may try to appeal the decision, asking the insurance company to reconsider, and filing all the reasons that may compel the insurance company to reverse their decision and help cover the costs.
Sounds simple enough although it’s anything but. The appeals process is needlessly complicated in an effort to discourage patients from going through it at all. There are multiple levels and reviews that must take place, and patients can get stuck on hold for hours at a time. This results in frustration and, for some, an immovable barrier, all for trying to get the treatment and care options their doctor prescribed.
Coinsurance and Copays
Having health insurance isn’t a guarantee that patient costs will be covered – far from it. Nowhere is this more evident than trying to understand the difference between coinsurance and copays, which are additional barriers by insurance companies to get patients to pay increasingly more of the share.
Coinsurance is the percentage of costs that patients are responsible for paying after they meet their deductible until they reach the maximum out-of-pocket limit. In some cases, insurance companies only cover certain services, meaning patients could get stuck with the whole bill. A copay is a set rate that patients pay every time they receive treatments or services. Copays apply regardless of whether patients have met their deductible. Both of these barriers – coinsurance and copays – force patients to foot more of the bill even though they have health insurance.
PBMs as Middlemen Meddlers
Pharmacy Benefit Managers, or PBMs, are middlemen companies in the drug supply chain that determine which medicines will be covered by health insurance plans and how much patients pay for their prescription drugs at the pharmacy counter. PBMs take the decision making out of the hands of doctors and their patients.
Barriers: Even if a doctor prescribes a medication, patients face barriers when trying to access that medication. That’s because a PBM may have a financial incentive to steer patients to other medications that are more profitable for the PBM but not in the best interest of the patient.
No Choice: PBMs pick medications that are allowed to be included on the list of prescription drugs covered by a prescription drug plan. This limits patients’ choice and incentivizes PBMs to place profits above patients.
PBM-Owned Pharmacies: PBMs require or financially steer patients to use the large pharmacies they own or have affiliations with rather than allowing patients to use their local pharmacy of choice.
Rebates: PBMs refuse to share rebates and discounts from pharmaceutical companies directly with patients at the pharmacy counter. Instead, they keep the savings for themselves.
How do they do it?
Absence of accountability. The three largest PBMs – which are owned by health insurers – control 77 percent of all claims. PBMs are among Fortune’s top 25 companies in the US (5). The drug pricing process’ inherent opaqueness and complexity allows PBMs to manipulate costs and undermine the possibility for competition that would drive value, savings and access for patients. PBMs also fight proposed laws that would allow states greater oversight and public transparency over them and their practices.
Bottom line: PBM practices enable them to limit choice of and access to doctor-prescribed medicines.