United Health Takes Novel Approach To Controlling Access To New Medicines
From The Hill:
UnitedHealth to Congress: Let cancer patients eat gauze
By Jonathan Wilcox
Investors are cheering the news that UnitedHealth Group, the nation’s largest health insurer, reported first quarter 2015 revenues of almost $36 billion, a 13 percent increase from last year that “beat the street” by exceeding forecasts. The company said revenues are expected to reach $143 billion this year, and specifically credited “more effective and more modern approaches” for the windfall.
What are UnitedHealth’s “more effective and more modern approaches”? Stripped of the self-congratulatory press releases, this dividend translates into something more worrisome for the tens of thousands of cancer patients dealing with rising copays, restricted coverage and all too often, access denied completely.
That’s why cancer advocacy organizations are taking action, pressing Congress and state legislatures to cap co-pays on specialty medicines and ensure equality of access and insurance coverage for all anticancer regimens. To date, 39 states have enacted oral chemotherapy access laws, while 15 states and the District of Columbia have either introduced or passed bills to limit what patients pay for specialty medicines.
Ask patients where these actions are necessary and you’re likely to hear about the detested practice of health plans requiring patients to use medication after medication until their insurance company agrees to pay for the drug actually prescribed by their doctor. Insurers have a benign term for this: “step therapy.” But cancer advocacy organizations call it something else: “fail first.”
Not only is this practice unjust, multiple studies show it increases costs to the health care system – particularly for hospital and emergency-room care — while compromising patient treatment.
Another onerous strategy is placing newer medicines (especially biologics) into “specialty tiers” – another dressed-up code word for patients having to pay up to 50 percent of the total cost of these therapies. This can cause patients to spend thousands of dollars for a single drug that is medically necessary, opt for less effective drugs or choose not to fill their prescriptions at all.
Then, there is the ritual of insurers covering the costs of intravenous or injectable chemotherapy drugs when patients are treated in a physician’s office or hospital, but not a major portion of the costs when patients take oral cancer drugs at home. The insurance preference for invasive infusions and harsher side effects is simply unfathomable to many patients.
According to the latest estimates, as much as 25 percent of oral anticancer medicine costs is shifted to patients in higher co-pays – as much as hundreds or thousands of dollars per month. As a result, almost 10 percent of insured patients don’t fill their initial prescriptions for these medications. They want to – they just can’t afford to.
Ten percent of cancer patients denied access to treatments their doctors prescribe and they need is no rounding error – it’s a national crisis.
Despite these facts, UnitedHealth and other insurers are blocking patients’ path to novel therapies because they say the price of new, targeted medicines is “not sustainable.” This may make short-term sense for the bottom line and the stock price, but it is hurting patients and damaging the broader economy.
But there is a simple solution for UnitedHealth and other health plans to solve this crisis. According to an analysis released last month by the Millman financial consulting firm, capping copays for many plans would increase premiums by less than 0.5 percent. For other plans, there are market-based ways to offset costs by increasing the copays for doctor visits by just $5.
These solutions also pay back: According to one analysis, innovative treatments and breakthrough cancer medicines are associated with 50 million life years saved over the last 15 years. The improved outcomes and increased survivability have reduced spending on hospital and physician care, amount to an economic gain of $1.2 million per person, and countless additional tax payments as employees live and work longer.
Right now a patient revolution is going on in this country, but it need not be at war with the insurance industry. By all means, let UnitedHealth grow its business and expand its bottom line. We don’t want to take away the insurance industry’s profits – all we ask is that while doing very well from patient premiums, insurers do some good for patient access, too.
Wilcox is the Public Policy director of Vital Options International, a national non-profit organization focusing on improving the lives of all Americans living with cancer. He is a fellow with the University of Southern California’s Unruh Institute of Politics and was a speechwriter for California Gov. Pete Wilson (R).