Andrea opened with some terms:
- Deductible: Upfront cost to patient before insurance contributes
- High deductible health plan: Health insurance plan with a high deductible but lower monthly premiums. Eligible for HSA
- HSA: Health Saving Account
- HRA: Health Reimbursement Arrangement
- FSA: Flexible Spending Account
- Premiums: Price of having your insurance plan (usually monthly) – can be shared with employer
- Out of Pocket Maximum: Max dollar amount patient will pay per year (after which insurer pays 100%)
- Co-Insurance – % paid by patient (e.g. 30%) and % paid by insurance (e.g. 70%) until out-of-pocket maximum is reached
- Cost Accumulator Plan: Portion of copay/co-insurance that is paid by copay cards but does not apply to patient’s deductible
- Maximizer Plan: Insurer applies total cost of a copay card upfront before insurer will contribute
High Deductible Health Plan (HDHP)
Pros: Protection from catastrophic cost / high deductible means lower premiums
Cons: Unexpected medical expenses can be devastating if a patient has no savings to pay the high deductible
One hospital stay can “eat up that whole deductible” – so have the money saved to cover the deductible.
Health Saving Plans
“All of these can be helpful.”
HSA – Health Saving Account – owned by employee / IRS approves expenses / employer and employee contribute to it / only valid with a HDHP
HRA – Health Reimbursement Arrangement – owned by employer / employer approves expenses / employer contributes to it
FSA – Flexible Spending Account – IRS approves expenses / employer and employee contribute to it
Problematic Clauses in Your Health Policy – “There are clauses in the plan design we usually don’t see”.
Cost Accumulator clause – prohibits copay assistance from counting towards an enrollee’s deductible and out of pocket max. Also known as “copay accumulators”, “benefit plan protection programs” or “out-of-pocket protection program”.
“So, if I have the ability to use a copay card for my biologic or drug that I’m being prescribed, (under a Cost Accumulator clause) only the portion that I pay counts towards my deductible.” E.g., If you’re on a biologic that costs $5000 but you have a copay card that leaves you just paying $5, then only your $5 goes towards your deductible.
“Sudden out of pocket costs can make patients drop therapies, which can lead to negative health outcomes.”
Cost Maximizer clause – “If you get a copay card worth $16,000, the insurer is going to use up that $16,000 before they contribute to the cost of your medication.” Medication costs would not be going towards your deductible and out of pocket maximum.
How Insurers Lower Costs
“Utilization Management” is the process of intervening in the doctor-patient relationship to reduce costs. Sometimes Pharmacy Benefits Managers (PBMs) intervene in an effort to save money.
Utilization management tools include:
Prior Authorization – mandates advanced approval of a drug or treatment.
Step Therapy / Fail First / Non-Medical Switching – forcing the patient to try cheaper (“lower tier) treatments before granting access to more expensive (“higher tier”) treatments.
Partial fills / Quantity limits – e.g., doctor prescribes a 90-day supply, but the PBM only partially fills it. PBMs can enact quantity limits on meds you’ve been on for some time as well.
The Harms Brought on by Prior Authorizations
Seeking authorizations like these are not just for prescription medications. They can also apply to lab tests, radiology etc.
In a 2020 American Medical Association (AMA) physician survey, 94% of physicians said prior authorizations delayed care, 98% reported having to resort to peer-to-peer conversations with payers, and 3% of physicians ended up abandoning the proposed treatment.
“My staff,” Andrea explained, “spends approximately 60-75 hours out of 400-working-hours per week, working on prior authorizations.”
Your Doctor’s Office Can Help You Fight These Policies
Some of the tools the physician’s practice can use to counter these anti-patient policies include:
- Making an appeal through the Payer’s portal (EHR)
- Calling the insurer/PBM
- Use a service like “Cover my Meds” (a patient-centered network to help patients get their RX covered)
The patient and the practice can gather information to support an argument to cover the RX. This could involve reviewing patient records, proving a letter of medical necessity, reviewing medical literature and studies (often for new meds or rare diseases), medication guides (medical associations, NIH, etc), and past therapies tried-and-failed.
“I tell my staff never to take no for an answer. The patient and physician’s medical decision is worth fighting for.”
The first way to appeal is using the payer’s established mechanism for appeal. Usually a form. If that process is denied, there is a second layer of appeal which is the peer-to-peer discussion by the physician to the payer’s medical advisors.
It’s also worth it for patients to call their insurance company or, in the case of employer sponsored plans, talk to their HR department. Patient input and feedback matters. “You are paying for this insurance. You have a say.”
Let My Doctors Decide