Exchange Plans’ Cost-sharing Confuses, Burdens Patients

by Amanda Conschafter, blog editor

Patients with federal exchange health care plans may not fully understand the extent of their out-of-pocket cost obligations, a new study shows. And for patients with cancer and chronic illnesses who need specialty medications, the weight of those costs – expected or unexpected – can pose a serious financial burden. So as countries across the globe observe World Cancer Day, Americans might consider how cost challenges could prevent U.S. cancer patients from receiving the best treatment available.

Patient confusion stems in part from the exchange plans’ use of specialty tiers. The marketplace’s most common specialty tiers structure includes four tiers. Tier one typically includes low-cost generic drugs that require a modest co-payment, while the fourth and highest tier includes the most expensive medications. These are often cell-derived biologic medications, cancer medicines and drugs for chronic or rare diseases. Tier four also carries the highest level of cost-sharing, typically presented as a co-insurance rate, or a percent of the drug’s cost.

Cancer Costs Turn Toxic infographic

Avalere Health recently reported that may not accurately reflect these specialty tiers’ out-of-pocket cost obligations for some patients. Though the website reports cost-sharing for plans with four-tier specialty structures, roughly 35 percent of plans do not use four-tier structures. For patients on these plans, therefore, obtaining accurate information on cost-sharing can be a challenge.

Lacking cost-sharing details can be worse than inconvenient. For patients who depend upon medication to sustain quality of life – or life itself – surprise out-of-pocket costs could put vital medications out of reach.

In fact, high co-insurance rates and other cost-sharing mechanisms place an increasing burden on patients, cancer patients in particular. A recent article from Pharmacy Practice News revealed that cancer patients are 2.56 times more likely to file for bankruptcy than their cancer-free peers are. The article also noted that one-third of surveyed cancer patients reported financial hardship as a result of their treatment, with patients struggling to pay for necessities and depleting their personal savings.

Rising cost obligations pose a significant risk to cancer care, as the Alliance for Patient Access’ recent “Protecting Cancer Care” video explains. But when cancer’s cost burden is compounded by a lack of clarity on out-of-pocket obligations, exchange health plan patients face a doubly challenging situation.

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