I’m shocked to discover that there is gambling going on in this establishment.
From today’s New York Times:
Study Finds H.I.V. Drugs Priced Out of Reach
Drugs to treat H.I.V. and AIDS are being priced out of reach for many patients enrolled in insurance plans through the new health care exchanges, despite warnings that such practices are illegal under the Obama administration’s health care law, according to a new analysis by Harvard researchers.
The study, to be published on Wednesday in an article in The New England Journal of Medicine, looked at 48 health plans in 12 states and found that a quarter of the plans showed evidence of what researchers called “adverse tiering,” or placing all of the drugs used to treat H.I.V. in a specialty tier where consumers are required to pay at least 30 percent of the cost of the drug.
The financial impact can be drastic, the researchers found: A patient taking a common H.I.V. treatment, Atripla, would pay about $3,000 more a year in a restrictive plan compared with someone enrolled in a more generous plan, even after accounting for the fact that the more restrictive plans tended to charge lower monthly premiums.
“That’s really a large cost difference, and really is a very significant financial constraint for those with chronic conditions, particularly H.I.V.,” said Douglas B. Jacobs, the lead author of the study, who is pursuing degrees in public health at the Harvard T. H. Chan School of Public Health and medicine at the University of California, San Francisco.
The study, which did not name the insurers whose plans it analyzed, looked only at the midlevel, or silver, plans offered in the marketplaces because they are the most popular plans among consumers. More comprehensive plans, known as gold and platinum plans, are often more generous in coverage but carry higher premiums. Insurers have said that these may be a better choice for people who have serious medical conditions.
Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group, said that a crucial component of the marketplace was consumer choice, and that the study should have included an analysis of the gold and platinum plans. “Individuals have diverse health and financial needs, and health plans have designed a wide range of coverage options, including those with lower cost-sharing, so individuals can pick the policy that is best for them,” she said.
Health insurers are prohibited from discriminating against people with specific medical conditions under the new federal health care law, and the law contains some provisions that help prevent such practices. Patient advocates and others, however, have said that some companies appear to be skirting the law by restricting access to all drugs that treat certain conditions.
In May, two consumer groups filed a federal complaint asserting that four insurers in Florida had discriminated against people with H.I.V. by making their drugs more costly and difficult to obtain. All of the companies have since agreed to make changes that would lower the cost of the drugs in 2015, although the federal complaint is still pending.
The latest study is “more confirmation that this is happening, not only in Florida, but in other states as well,” said Carl Schmid, deputy executive director of the AIDS Institute, one of the groups that filed the federal complaint.
In December, the Obama administration said that it would investigate insurers’ prescription drug coverage, and told insurers that companies that place most or all drugs that treat a condition on the highest-cost tiers are effectively discriminating against people with those conditions.
In an effort to contain the rising cost of prescription drugs, many insurers are requiring extra steps for people who need the drugs or raising out-of-pocket amounts that patients must pay. The insurers say such practices are necessary to keep premiums low and to encourage patients and their doctors to make cost-effective decisions, like choosing a cheaper generic over an expensive brand-name drug.
But what makes these cases different, the researchers said, is that the insurers restricted access to all drugs that treat H.I.V., even less costly generics, leaving patients who have the virus with few options.
Limiting access to H.I.V. drugs could benefit insurers because it might discourage people with such conditions from signing up for coverage. But the study’s authors warned that if left unchecked, a small number of insurers — those offering the most generous coverage — could end up shouldering the burden of caring for the sickest patients.
If the more generous plans end up with a disproportionate share of sicker members, they could, in turn, adopt more restrictive practices. “It could, in essence, be a race to the bottom on drug benefit designs,” Mr. Jacobs said.