Insurance exchanges fail colon cancer patients
Colon cancer will claim the lives of more than 50,000 Americans this year. It’s a disease we should all take personally. One in 20 people will be diagnosed at some point in their lives — and it affects both men and women almost equally.
Fortunately, thanks to better screening and groundbreaking new treatments, the death rate from colon cancer has been dropping for more than 20 years. But even the best screening and treatment can’t help those who are unable to afford the cost.
Nearly 40 percent of patients undergoing treatment for colon cancer experience severe financial hardship. And if you have health insurance and think you’re in the clear, you had better take a closer look at your policy. In the case of treatments for numerous diseases including colon cancer, many insurers shift the cost burden of medications to unsuspecting patients in an effort to improve their bottom line.
Although it’s known as the Affordable Care Act, some elements of the new health care law are actually exacerbating this disturbing trend.
The federal and state governments have set up online insurance marketplaces — the so-called exchanges — to allow individuals and businesses to purchase insurance. All exchange plans are required by law to cover prescription drugs. Each insurer maintains a list of prescription drugs, a formulary, that specifies the drugs it will cover. But most formularies have four or more “tiers” of coverage that place increasing cost-sharing obligations on patients. The surprise comes when you develop a condition whose medications fall into the top tier.
The first tier, usually for the most commonly prescribed medications, might include a modest copay of, say, $20. But the highest tier typically involves co-insurance, in which the patient is responsible for a fixed percentage of the cost of a drug, no matter how high. The coinsurance percentage can run to 40 percent or more for drugs that can cost thousands of dollars.
What this means in practice is that patients can get stuck with huge bills. The impact here falls disproportionately on patients with serious medical conditions that require expensive medications — such as cancer, multiple sclerosis and HIV/AIDS.
Since a cancer diagnosis can come as a surprise, it’s impossible to plan in advance for the most effective insurance plan. People in that position lose the lottery twice: first with suddenly getting diagnosed with a life-changing condition, then with the bad luck of the financial sacrifice they may have to make to save their lives and get the treatment they need.
Tier-pricing is prevalent across exchanges. A recent study by Avalere Health analyzed 123 mid-level exchange plans and found that more than 60 percent place all medication for cancer and other life-threatening conditions on the highest cost-sharing tier.
Such high out-of-pocket drug costs threaten to put medically necessary treatments out of reach for the patients who need them most. Patients are left with little choice but to deplete their savings or retirement funds, declare bankruptcy, or skip or refuse treatments.
Researchers at Duke University Medical Center surveyed cancer patients to learn how they coped with these costs. Nearly half described the financial burden as “significant” or “catastrophic.” Forty-six percent had to cut back on basic needs such as groceries. Eighteen percent of patients sold personal possessions or property to help pay for care.
The greater the cost-sharing, the more likely a patient will postpone or forgo medication. According to a study by University of North Carolina researchers, patients with higher co-payments were 70 percent more likely to stop taking their cancer treatment and 42 percent more likely to skip doses.
This is a serious, life-threatening problem. Skipping treatments significantly increases the risk of relapse. Missing even just 15 percent of a prescribed dose can lead to a recurrence of the cancer.
Specialty drugs have offered notable help to patients, and their higher prices reflect the manufacturers’ years of research and development investment. This innovation is remarkable and it is improving health outcomes for patients. However, making these medications cost-prohibitive for the patients who can benefit most from them is the current unfortunate reality many patients are left with.
Getting a colon cancer diagnosis is bad enough without adding exorbitant and disproportionate out-of-pocket costs for treatment. If the new health law is to live up to its promise of affordable care, lawmakers must create a solution and help people get the care they need and deserve.
Jasmine Greenamyer is the chief operating officer of the Colon Cancer Alliance.