Managed care has been an inescapable part of healthcare for decades. We encounter it collectively as healthcare providers and individually as healthcare consumers. The ways in which managed care plans pay for services, as well as the services for which they pay, underpin the provision of almost all healthcare in the United States. Managed care options and reimbursement are critical points in the discussion of healthcare reform.
Tiered copayments for prescription drugs have long been a part of insurers' cost containment strategies, with patients paying fixed amounts from their own funds when a prescription is filled; the dollar amounts vary depending on the cost of a particular drug and whether a less expensive-generic-alternative exists. Generic drugs were nearly always less expensive for the individual consumer because competition from generic drugs "is the most effective way of slowing the spiraling cost of pharmaceuticals" (AARP's Brief Amicus Curiae, 2010). Drug copayments were traditionally divided into three tiers; copayment costs were less for Tier I drugs and more expensive for Tier 3 drugs. The incentive to choose a generic form of a drug, when available, was lower cost.
Now, however, the growing number of biologic drugs available to treat cancer, immune disorders, and a variety of chronic illnesses-including multiple sclerosis (MS)-has caused some insurers to create a fourth copayment tier. This fourth tier has been introduced for drugs that are particularly expensive, and patients are being asked to pay a significantly larger "share" of the cost, often as much as 20%-30% of the fixed cost of these agents. Included in the Tier 4 group are drugs like the tumor necrosis factor blocker etanercept, trastuzumab (Herceptin), the interferons, and glatiramer acetate (Copaxane). Patients who require Tier 4 drugs are likely to incur "[horizontal ellipsis]out-of-pocket (OOP) expenses which far exceed what their budgets can bear" (Lee & Emmanuel, 2008, p. 333). Newer oral biologic agents will have no generic equivalent, will be patent protected for many years to come, and will certainly be classified as Tier 4 agents in terms of copayments.
What does this mean for our patients? The evidence tells us that as OOP costs rise, adherence to therapy falls. A study reported in the Journal of Managed Care Pharmacy (Gleason et al., 2009) indicated that OOP expenses greater than $200 for MS medication were associated with increased prescription abandonment; in other words, patients simply stopped having their prescriptions filled. Their analysis of administrative claims over a 2-year period found that individuals were 8% more likely to stop therapy for every $10 increase in OOP drug costs.
More than 400,000 individuals in the United States have been diagnosed with MS, and an additional 10,000+ new cases are identified annually. Adherence to current biologic treatment regimens is complicated by injection anxiety, adverse reactions to the injections, real and/or perceived lack of efficacy, and cost. Discontinuation or abandonment rates are between 9% and 20% in the first 6 months of treatment (Lipsy, 2010). As newer, oral biologics enter the treatment arena and market, patients will be able to choose a drug that does not require injection-a huge positive in maintaining adherence to treatment. The downside is that these drugs will have no generic (cheaper) form for many years and will come onto the market with Tier 4 copayments.
How do we, as neuroscience nurses, play a role in this unfolding economic scenario? We can advocate for better, more cost-effective access to treatment. We can campaign for changes in the Food and Drug Administration process for approving generic drug formulations. We can lobby for modifications in the structure of tiered copayment. We can teach patients and families to care for themselves in ways that promote optimal outcomes. We can become actively involved in the larger discussion of how we, as healthcare providers and individual consumers, will deal with rising healthcare costs in general. To paraphrase the Golden Rule, we should "manage others that way we would like to be managed."
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