Perhaps the situations that follow sound familiar to you. In fact, they most likely do. You have patients who meet at least one of the following criteria:

  • They struggle to afford their medications.
  • They signed up with a particular insurer for the medication coverage.
  • They have conditions that make specific medications necessary.

And then in the middle of the year, with little or no notice, the insurer raises the price of a needed medication from, say, $10 a month to $300 a month, or from $100 to $500. Patients are no longer able to afford it and must try other medications with disastrous results.

Fortunately, some states have noticed, and they are doing something about it. California and Nevada, for example, have rules now that insurers cannot significantly increase the cost of a drug in the middle of a year, nor can insurers decide to stop covering a drug without a valid medical reason. And even before California and Nevada took action, Medicare had regulations in place to prevent midyear “surprises” or to limit their impact. (There are no such Medicaid regulations.)

Cost-Effective Rules

To insurers and for insurers, these new rules may appear to not be cost-effective. However, in the long term, they probably are. Imagine a man, 70 years old, who is on a drug for type 2 diabetes. His insurer suddenly jacks up the price of the medication, and he is forced to go without it or to skip many doses. He likely cannot do this without repercussions such as hospitalization, which can lead to amputations, coma and much more. Who has to cover a lot of these costs? The insurer, of course.

Similarly, envision someone who is on an antidepressant, and the insurer decides to increase the price. The patient switches to a less-expensive drug and experiences psychosis, migraines, suicide attempts and more. Again, the long-term cost can be heftier than if the insurer had simply kept price increases modest. Changing drugs midyear for patients with cancer, mental illness, HIV and other chronic conditions often entails dangerous trial and error, and it may not always end with a suitable replacement.

If the Food and Drug Administration deems a drug is dangerous, the rules in California and Nevada allow insurers to drop them. So, patient safety in this regard is not an issue.

Arguments Against the Rules

Insurers and pharmaceutical companies have a few arguments against the rules. They say that being able to make quick changes makes it possible for them to offer the most recent and proven medications. They also lament the fact that drug companies often hike up drug prices. Moving the costs onto patients gives patients the opportunity to decide whether they want to pay more or try less inexpensive options.

It will be interesting to see how insurers in Nevada and California (a huge market) will fare with the new rules. The fact is that insurers tend to make the midyear changes when another drug is discounted or when a new drug, often more cost-effective, is available. Whether insurers actually make midyear changes for the benefit of the patient (a better, more effective drug, for example), is questionable.

There is no question that the demand from patients exists. Florida is debating setting up rules similar to those in Nevada and California, and Tennessee and Massachusetts may be next.

Giving Patients More Control

One reason why midyear surprise changes frustrate doctors and patients so much is that they strip patients of control. Patients may have signed up with a specific insurer because of its drug coverage and drug costs, and they feel attacked when they no longer get the coverage they pay monthly for. Nor can they simply seek out other insurers; they are locked in for the year. It seems unfair that they must keep paying premiums, yet insurers can do whatever seemingly strikes their fancy.

In fact, convenience and control matter a huge amount to patients. As an example, Proficient Rx offers an in-office dispensation system that enables your patients to bypass the pharmacy. Benefits include a reduced error rate and time savings for patients (no drive to the pharmacy and waiting there). Virtually any type of medication is available, and if you are in a state where insurance hassles are the norm, the one-stop convenience may offset some frustrations that patients feel.