Approximately one in four Ohioans live with arthritis – a painful and often debilitating condition that can be expensive to treat. Unfortunately, a policy too often used by health insurers is preventing thousands of Ohioans from being able to afford the medications that can help ease their pain.
There is no cure for arthritic diseases such as rheumatoid or psoriatic arthritis and others, but early treatment and lifestyle changes including diet modifications, exercise, surgery, and medicine can reduce movement limitations and joint damage. Lighter cases of arthritis are often treated with over-the-counter medications such as acetaminophen or NSAIDs and help with pain and inflammation.
Patients living with more serious cases of arthritis are often prescribed more powerful and significantly more expensive medications, called biologics. These types of medications are created from living sources and are more complex than other drugs. Biosimilars are the generic forms of biologics and while less expensive, they are still costly.
To offset the cost of medication, patients with high-deductible health plans have relied on third-party assistance, which could come from a drug manufacturer or a charitable foundation. However, health insurers and pharmacy benefit managers (PBMs are the drug-supply chain middleman) recently have implemented policies they call co-pay accumulators which prevent patients from benefiting from the assistance.
The insurers “accumulate” the financial assistance the patient receives but don’t apply the funds to the patients’ out-of-pocket expenses such as their deductible or copay. Once a patient’s assistance runs out, they require the patient to pay their entire deductible to access their medication.
The insurers do not return the assistance to the entity that provided the support, nor do they assist the patient. They double-dip and add to their profits all at the patient’s expense.
This practice of cost-shifting to the patient now occurs in nine of 10 Ohio health plans and unfairly target patients who need expensive medications to treat diseases, including arthritis, multiple sclerosis, cancer and thousands of rare diseases. Almost all (99.6%) of financial assistance for medications is currently used for drugs in which there are no generic equivalents.
Even worse, co-pay accumulators hurt the patients who need the most help. Almost 70% of patients who rely on third-party assistance earn less than $40,000 a year.
As a provider, I see patients every day who are trying to manage their disease but struggle with the financial implications. Many now never reach their deductible and are more often delaying and sometimes stopping their care and treatment. For my arthritic patients, this leads to flareups which, in addition to causing permanent joint damage, leads to treatment that is even more of a financial burden for them, their family, and our entire healthcare system.
The General Assembly is working to help Ohio patients by reforming co-pay accumulator policies in the state. Ohio House Bill 135, sponsored by Rep. Susan Manchester, a Republican from Waynesfield, and Rep. Thomas West, a Democrat from Canton, bans co-pay accumulators unless a generic equivalent of the medication is available. It was voted out of the House unanimously, 86-0, and waits consideration in the Ohio Senate Health Committee.
Sixteen other states and Puerto Rico have passed laws either banning these policies or regulating how they are used. More than a dozen other states are working on similar legislation.
House Bill 135 could help more than 1.5 million Ohioans save money on their prescription medications by making sure that their state-regulated health plan applies any form of patient financial assistance toward their cost-sharing limits. On behalf of rheumatology providers in Ohio and the tens of thousands of patients we care for, I encourage members of the Ohio Senate to vote yes for House Bill 135.
Dr. Elisabeth S. Roter, the president of the Ohio Association of Rheumatology, practices medicine with the University Hospitals system.