Healthcare Costs
5.5 minute read
Our Position
Access to the right medication at the right time is best decided between a consumer and their doctor. This is the main guiding principle for CTD when working on pharmaceutical policy issues, including access to medication, drug regulation and enforcement, and pharmaceutical research and development.
We are pleased to report several major successes from 2023:
- HB 999 (Price) will protect consumers from copay accumulators. When a consumer receives copay assistance, a copay accumulator prevents those funds from counting toward their annual deductible or other out-of-pocket requirements. This makes it harder for consumers to meet their deductible or maximum, resulting in higher out-of-pocket costs. After 3 sessions, a ban on copay accumulators finally passed.
- HB 755 (Julie Johnson) will prevent commercial insurance from requiring a pre-authorization before every infusion for people with auto-immune disease. People who need infusions generally stay on them for long periods of time, and this bill will remove an administrative burden.
- HB 1283 (Oliverson) will preserve a single Medicaid formulary. A formulary is a list of prescription medications covered by an insurer, in this case, Medicaid. Medicaid health plans in Texas currently all use the same formulary, but that was scheduled to be broken up into to as many as 19 separate Medicaid formularies. All those drug lists would be very complicated for consumer choice. Fortunately, a bill to continue a single formulary passed.
HB 826 (Lambert) / SB 1221 (Zaffirini), would have protected Texas patients from non-medical switching by preventing commercial health plans from switching stable patients from a medication between plan years for no medical benefit and solely due to cost. This measure did not pass.
The Latest
November 22, 2023: State House host Frank Santos and Dennis Borel talk healthcare, pharma, and Medicaid policy: The Challenges and Triumphs in Accessible Healthcare with Dennis Borel Part 1 (video)
June 10, 2022: Read our op ed in the Gilmer Mirror on How PBMs are hurting Texans with disabilities
April 8, 2022: Texas Healthcare & Biosciences Institute Pres & CEO Victoria Ford explains what pharmacy benefits managers (PBMs) are and why they matter to Texas consumers. Read her Rio Grande Guardian op ed: Texas can take action to lower prescription drug costs
Partners
- Texas Coalition for Stable Patients
- Texas Rare Alliance
Background
Non-medical Switching
Non-medical switching is a set of tactics that health insurers and pharmacy benefit managers (PBMs) use to switch stable consumers off their already-prescribed medications for non-medical reasons. It can take months, or even years, for a person with a chronic condition and their doctor to find an effective medication; insurance companies should not stand in the way of their stable health.
Being forced off the right treatment is common and costly for Texans:
- 67.7% of Texas patients reported that a change in their health plan’s formulary switched their medication to one different from what their provider prescribed.
- 73.6% reported being financially coerced by their health insurer to change their prescribed medication for non-medical reasons.
- Medication nonadherence annually costs the U.S. health care system $100 billion.
- Annual indirect costs exceed $1.5 billion in lost earnings & $50 billion in lost productivity.
Restricting non-medical switching will help Texans stay healthy:
- Out-of-pocket costs will remain predictable throughout the health plan year and from one year to the next within the same plan.
- Patients and their health care providers can trust that the treatment plan they make will continue to be covered.
- Stable patients won’t have to abandon treatments they depend upon while they and their providers try to appeal coverage denials or reductions.
In 2021, CTD joined the Coalition of Stable Patients to work hard to pass HB 1646 (Lambert), which would have helped Texas patients by reforming the insurance practice of non-medical switching. Unfortunately, we ran out of time to get this legislation across the line in time.
Our state already has a strong record of patient protections. In 2023, we are asking members of the Texas Legislature to reform the insurance practice of non-medical switching to allow patients to remain stable on a medication that has been prescribed by their physician and covered by their health plan, as long as they remain on that same health plan. This will benefit the health of the patient, improve continuity of care, and reduce medical costs for the patient and for the Texas healthcare system.
Copay Accumulators
Texas has led the nation on important patient protections, but barriers still exist, including rising out-of-pocket costs for consumers. Particularly for Texans with complex chronic conditions or rare diseases, affording these out-of-pocket increases can be daunting, and many consumers rely on copay assistance programs. Through these programs, drug manufacturers or other third parties offer copay cards or coupons that help consumers to meet their insurer’s annual deductible and out-of-pocket requirements.
However, a growing number of insurers and pharmacy benefit managers (PBMs) are implementing Accumulator Adjustment Programs or copay accumulators. When a consumer receives copay assistance, a copay accumulator prevents those funds from counting toward their annual deductible or other out-of-pocket requirements. This makes it harder for consumers to meet their deductible or maximum, resulting in higher out-of-pocket costs.
Ho do copay accumulators affect Texas patients?
- In recent years, copay accumulator adjustment programs implemented by health plans do allow patients to utilize copay assistance, but no longer apply those dollars toward the patient’s deductible and cost-sharing requirements for their covered treatments.
- Oftentimes, patients are unaware their health plan includes a copay accumulator program, as the notification language is often buried or misleadingly worded in the plan’s legalese.
- Patients are surprised at the pharmacy counter when they learn their copay assistance dollars have run out but were not applied to their deductible, so to continue on their prescribed drug, their health plan requires them to pay out of pocket for the full cost of the medicine until they reach their deductible again. This forces many to abandon the treatments that would keep them healthy and productive.
In 2021, we urged the Texas Legislature to step up and protect consumers from copay accumulators, a new insurance practice that raises individuals' healthcare costs. HB 2668 (Price) / SB 523 (Buckingham) would have ensured that health insurers apply ANY copayments toward a consumer’s deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum requirements under that consumer’s health plan. However, this bill did not pass.
Further Reading
- Video: RYV! Access to Medicines (recorded Nov. 18, 2020, Copay Accumulator topic begins at 36:30)
