Out-of-Pocket Costs Are Pushing Patients to the Brink

It happened again just last week.  A patient cried as she explained to me that she can’t afford the out-of-pocket cost of her medicine.  How, even with a second job, she’s forced to choose between paying for her two types of insulin and putting food on the table for her family.  

As a science teacher, she knows the irreversible damage she’s causing herself by rationing her meal-time insulin.  But, like many diabetes patients, she feels she has no other choice.

Many cardiovascular disease patients are in similar situations.  Just look at PCSK9 inhibitors, which can reduce “bad” LDL cholesterol, protecting patients from heart attack and stroke.  Even still, insurance companies denied almost 40 percent of PCSK9 claims last year. But the lucky patients whose insurance will cover the medicine still may not be able to take it because their share of the cost is prohibitively high.

Patients with both diabetes and cardiovascular disease face a double whammy, high out-of-pocket costs for both medicines.  I see these patients regularly, because the two conditions share many risk factors, including hypertension, abnormal cholesterol and obesity.  And patients with diabetes often develop cardiovascular disease.

With each of these patients, I have the same thought.  Patients shouldn’t have to choose between food and medicine.  Or between one life-saving medicine and another.  Insulin and PCSK9 inhibitors are just two examples; there are others.  And the millions of patients who rely on daily medicine to keep them alive deserve solutions.

I’ve seen encouraging progress over the last year.  Manufacturers of two PCSK9 inhibitors slashed their prices.  And earlier this month, media outlets reported that a generic insulin product is forthcoming, available at half price.

Now it’s insurers’ turn to act.  Health plans must respond by including these medicines on their formularies, at their lower price points.  They must step back from budget siloes for pharmaceutical, doctor and hospital costs, and consider a patient’s overall expense.  They should contemplate whether a little extra cost in the pharmacy budget line isn’t an investment that can prevent emergency care or a costly hospitalization.  Good medication adherence can also delay the onset of other conditions and their associated expense.

It’s not enough to sympathize with tearful patients.  Health care providers and advocates must demand policy changes that keep out-of-pocket costs manageable for patients.  And health plans need to heed those demands – creating formularies, coverage policies and cost-sharing structures that prioritize patient health.  

Kari Uusinarkaus, MD, is a family medicine physician, lipidologist, and specialist in clinical hypertension in Colorado Springs.

This post is part of IfPA’s “By All Accounts” blog series.  Each month, a different guest author – and a different story – adds a new piece to the common narrative of how insurance practices meant to control costs are instead hurting patients.

Tags: , ,

Categorized in: