Volume 11 Issue 77
Published - 14:00 UTC 08:00 EST 22-Mar-2009 
Next Update - 14:00 UC 08:00 EST 23-Mar-2009

Editor: Susan K. Boyer, RN
© Vidyya.
All rights reserved.



Patients suffer as a result of insurance pricing scheme

(22 March 2009: VIDYYA MEDICAL NEWS SERVICE) -- Millions of patients suffering from diseases such as rheumatoid arthritis, multiple sclerosis, hemophilia, hepatitis C and certain types of cancer are at risk of incurring thousands of dollars in medical expenses due to a new pricing system being implemented by many insurance companies across the United States.

Health insurance companies are rapidly adopting this new system, commonly called Tier IV, for many of the expensive drugs used in the treatment of several diseases – asking patients to pay hundreds and even thousands of dollars a month for needed prescriptions. Blue Cross Blue Shield of Mississippi was one of many insurance companies to adopt this system, forcing its policyholders to shoulder 20 to 40 percent of the costs of their medication.

Traditionally, individuals and families pay reasonable co-pays for medications as part of their health insurance coverage, such as $15 for generic, $20 for brand name, or $30 for off formulary. Tier IV pricing goes above-and-beyond the traditional co-pay, forcing patients to pay hundreds or thousands of dollars out-of-pocket each month. For many rheumatology patients affected by Tier IV pricing, these costs are staggering, and because Tier IV often applies to the most expensive medications (such as infusions) these patients often consider other options, including stopping treatment.

"The Tier IV pricing system essentially represents discriminatory pricing for certain patients,” explains Charles King, MD, a rheumatologist in Tupelo, Miss. “Asking my patients to pay 20 to 40 percent of their drug costs out-of-pocket (often up to $600 each month) means they will not have access to these life-altering therapies. My office has been flooded with calls from worried patients since the Tier IV system took effect. They are fearful of losing access to medicines that afford them the ability to lead independent, productive lives, and this is of great concern to me as their rheumatologist.”

Robin Bates, a 34 year-old patient of Dr. King’s has suffered from rheumatoid arthritis since she was 21, and was faced with the challenge of purchasing her expensive Tier IV treatment from a specialty pharmacy assigned to her by her insurer. Her treatments were costing her well over $1,000 per year on top of her insurance premium, leaving her baffled as to why this was happening.

“I can’t function without my medication, and I have four small children and a husband who need me; I have to be able to get up and go,” says Bates. “But, this Tier IV pricing system made me wonder if I could find a cheaper medication—which I couldn’t—and for a moment, I stopped considering the best option for my treatment, and started looking for the most affordable one.”

Charged by this kind of fear and frustration, physicians, health care professionals, patients and caregivers in Mississippi recently rallied together and overwhelmed phone lines and message boards demanding fair pricing and appropriate access-to-care, and their efforts worked. As a result of this action, Blue Cross Blue Shield of Mississippi has lowered out-of-pocket expenses for Tier IV drugs to 10 percent of the cost of the drug – with a $200 maximum co-pay per month.

“I am pleased that BCBS of Mississippi has realized the importance of assuring access to these medicines, and has taken the lead in putting patient’s needs first. My hope is that other insurance companies nationwide will follow the example set by BCBS of Mississippi," says Dr. King.

It is important for physicians, patients and caregivers in all states to come together and fight this unfair pricing system, which has lead to a severe access-to-care issue. For the Mississippians who rallied against Tier IV pricing, the results were great – they influenced change in one of the biggest insurance companies in the United States.

According to the American College of Rheumatology’s President, Sherine Gabriel, MD, this type of grassroots action is what causes change. “Picking up the phone and making a call to your insurance company, contacting members of Congress, contacting local news outlets, and simply learning more about Tier IV pricing can make a huge impact in your state, just as it did in Mississippi,” explains Dr. Gabriel.

The action taken after local news coverage of this issue in Mississippi led to the reform of an insurance policy that was damaging to the health of many residents, and Dr. Gabriel believes that this groundswell of action is what caused the change in policy. “Insurance policyholders have the right to question unfair pricing and should fight for reasonable pricing for their treatment and the treatment of their loved ones,” she says. “Patients acquire insurance so they won’t have huge out-of-pocket expenses, and Tier IV pricing makes that protection null-and-void.”

Being positively affected by BCBS’s recent policy reform, Bates urges other patients to take a stand. “If everybody sits back quietly, nothing will change. If nobody calls, they [the insurers] will continue to do this, and the prices could go up even more,” she says.

Those concerned about Tier IV pricing in their state can take two simple steps:

  • Call your insurance company and make an official request that they do not adopt this pricing structure, or request that they do away with their current Tier IV pricing structure.

  • Ask your lawmakers to take a stand against Tier IV pricing that places an unfair burden on many constituents with serious health conditions. Reach your lawmakers through American Medical Association’s toll-free grassroots hotline at (800) 833-6354.

To learn more about Tier IV pricing, how it can cause major out-of-pocket expenses for you or someone you love, and how to fight it in your state, http://www.rheumatology.org.

The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases.

Return to Vidyya Medical News Service for 22 March 2009

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Information appearing on the Vidyya Medical News Service is not intended as a substitute for professional medical care. Seek professional medical help and follow your health care provider's advice.

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