Healthcare Costs

5.5 minute read

Healthcare icon: grey heart with white cross insideOur 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 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



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:

Restricting non-medical switching will help Texans stay healthy:

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 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