By Angela Young
It may come as a surprise that arthritis is one of the most common illnesses among Kentuckians with more than one million residents suffering from arthritis or related diseases. In fact, Centers for Disease Control data shows that arthritis is the leading cause of disability in our country as conditions like rheumatoid arthritis, psoriatic arthritis, juvenile arthritis, lupus and other severe forms can be extremely painful and debilitating.
Fortunately, breakthroughs in new medicines—particularly biologic drugs—that treat many forms of arthritis, including rheumatoid arthritis, juvenile arthritis, lupus and others, are helping prevent disability and allowing patients to function and remain in the workforce.
Hefty Price to Pay
Along with the effectiveness of these treatments can come a hefty price tag for consumers as insurers often place such drugs in what is known as a specialty class or tier. A specialty tier pricing system is also commonly referred to as a cost sharing or co-insurance model. Under this system, medications are broken into tiers (one through five) based on their cost, increasing in price respectively. For tiers one through three a typical co-pay ranges from $5-$60, capping out at the latter. However, for tiers four and five consumers are forced to cover anywhere from 20-50 percent of the costs out of their own pockets. The insurers’ special cost of these medicines can reach several hundred to even thousands of dollars a month— something many Kentuckians simply cannot afford.
Of course, patients with arthritis aren’t the only ones affected. These cost sharing models are used for a variety of medications, including those treating chronic diseases like cancer and diabetes. These innovative new medicines are often the most effective in treating symptoms for patients and helping them live more productive and independent lives.
This certainly begs the question that, if a patient is seeing successful results with a specific medication, does it makes sense for them to be forced off that medication just because they can not afford to pay these unexpectedly high, insurer-driven costs?
Groceries or Medicine
No matter what the insurers choose to call it, this pricing model puts patient access to critical medications at risk, forcing them to forgo life necessities, including groceries, gas to get to work, or rent, in order to cover the costs of medicines that allow them to function.
Kentuckians must have access to the medications that work best for them not just because they can reduce symptoms and improve quality of life, but because it means saving on long term catastrophic care and promoting a more productive workforce. When patients are utilizing the most effective treatment plan, it cuts down on emergency room visits and hospitalizations caused by switching or using a less effective medication.
The prevalence of arthritis – attributable work limitation in Kentucky is as high as 51 percent. So while insurance companies may save money in the short run, by passing large percentages of the cost of specialty medications onto patients, they are actually costing themselves and our economy much more.
Fortunately, there is a solution. These so-called specialty medication prescriptions should be capped at a reasonable amount just like their lower tier counterparts. This will ensure patients are able to seek the treatment they need at prices they can afford. The Kentucky General Assembly established a meaningful precedent in 2014 by passing oral chemotherapy fairness legislation requiring insurance plans to provide the same level of coverage for oral chemotherapy drugs as provided for intravenous or injected treatments.
Legislators should take the next step to protect all Kentuckians who need these medicines and ensure any required co-payment or coinsurance on specialty tier medications does not exceed $100 per month for any single 30-day medication supply or that the amount paid by the patient in the aggregate (meaning the out of pocket costs to the patient for all of their medications combined) does not exceed $200 per month.
It is important that we do not disrupt the care and treatment of Kentuckians. If quality of life and patient independence weren’t enough, improving the productivity of our workforce and reducing the number of Kentuckians on disability is a good reason to implement this new model. Kentuckians must be allowed to stay on the medications that work for them. No one should have to choose between a life of pain or going without basic necessities.
Diagnosed with arthritis herself and the mother of a child with juvenile arthritis, Kentuckian Angela Young and her son are two of the many “ faces of arthritis.” As an Arthritis Foundation advocate and Ambassador, she regularly speaks out on issues that impact people with arthritis.