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Rain showers this evening with overcast skies overnight. Low near 40F. Winds WNW at 5 to 10 mph. Chance of rain 50%.
Having health coverage, even when you didn’t have it before the Affordable Care Act, still may mean you can’t get the medicines you may need.
Insurance companies call it “benefit design,” but consumer watch-dog and patient safety groups call it “adverse tiering.” Those of us on the front lines of patient care know it simply as bad medicine. That is, the choices your prescriber presents you for treatment of your chronic health condition may be less about his or her professional judgment and more about what your insurance plan is willing to pay.
Tiering is how health plans use various incentives to influence how you and your doctor select a medication to treat your condition. It’s not surprising that these incentives have been shown to effectively bolster the insurance company’s bottom line. What is surprising is that these incentives can effect who even bothers signing up for insurance in the first place. By making it more costly or difficult to prescribe medications for a particular kind of problem or group of people, health plans can cherry-pick their customers.
Findings published recently in the New England Journal of Medicine by researchers at Harvard’s School of Public Health showed that one quarter of health plans surveyed used adverse tiering to limit patient access to certain HIV drugs. Even when lower premiums and Affordable Care Act caps on out-of-pocket expenses were factored in, someone enrolled in an adverse tiering plan would still pay $3,000 more than someone enrolled in the other plans. But it doesn’t just stop there.
Doctors who treat medically complex patients with multiple chronic diseases know that adverse tiering can have life threatening implications. For my specialty of pain management, this means that “tiering” patients into first failing attempts of dangerous drugs, when safer abuse-deterrent formulations may be more appropriate, forces prescribers and patients into bad prescribing practices.
The good news is that new rules now under consideration by Oregon legislators would encourage safer opioid prescribing practice by removing any disincentives to prescribing abuse-deterrent painkillers. Other protections include requiring insurance carriers to provide coverage for abuse-deterrent opioids as preferred drugs on their formulary, requiring that the cost-sharing for abuse-deterrent opioids not exceed the lowest cost-sharing applied to prescription drugs, and prohibit an increase in patient cost-sharing. Massachusetts passed a similar law last year.
Oregon health providers and leaders, as well as policy makers, must pay attention. When it comes to reducing opioid over-doses and deaths in our state, prescribers need every arrow in their quiver. This means that insurance companies shouldn’t be allowed to prioritize cost over patient safety. When a prescriber judges that an abuse-deterrent formulation is a safer and more appropriate option for a patient, that judgment should be honored by payers and at the pharmacy pick-up window. Using tools such as abuse-deterrent formulations, prescription drug monitoring data-bases, enhanced patient surveillance, and evidenced-based prescribing guidelines, together we can stem the tide of deaths and dysfunction caused by prescription pain-killer abuse in our state.
Dr. David Russo is a physiatrist and pain management specialist with Columbia Pain Management P.C. in Hood River.
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