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Evidence Mounts of Insurer Discrimination against HIV, HCV Patients

April 20, 2016
We’ve written before about the problem of discriminatory formulary design in health insurance plans, particularly for patients with high-cost health conditions. Evidence continues to mount that the practice is widespread and poses substantial barriers to accessing needed medicines for patients with potentially deadly and debilitating diseases like HIV and hepatitis C.

Late last week, New York Attorney General Eric Schneiderman sued a health plan, alleging that it refused to pay for hepatitis C drugs except for patients with an advanced stage of the disease. Pharmalot’s Ed Silverman noted in his coverage of the lawsuit:
By failing to disclose that cost is a consideration when deciding “medically necessary” treatment, New York Attorney General Eric Schneiderman alleged that the insurer is misleading consumers and violating state laws, according to the lawsuit, which was filed in state Superior Court in Manhattan.

The problem goes well beyond New York. Yesterday, the Boston Globe reporter Felice Freyer wrote about the problem in Massachussetts:
Many insurers in Massachusetts, worried about the high cost of those medications, allow their use only for patients whose livers already show signs of severe damage, despite guidelines from major medical societies recommending treatment for nearly everyone infected with hepatitis C.

The Globe looked at data from the Center for Health Law and Policy Innovation (CHLPI) of Harvard Law School, which just released two new state assessments of Qualified Health Plans in state Marketplaces for Massachusetts and Michigan:
The center found that in nearly half the [Massachusetts] plans, patients had to pay a higher percentage of the cost for hepatitis C drugs than for most other drugs. Some insurers require patients to pay half the cost.

Yesterday, the Globe highlighted the plight of a patient suffering from hepatitis C, who stated “It makes me feel angry at the insurance companies…”  “I’ve worked all my life, had health insurance all my life. I’ve been waiting for this cure to come along — and now I can’t get it.”

Today, the Globe reports that one insurer featured in yesterday’s story, Tufts Health Plan, has reversed its previous policy of restricting coverage of the drugs only to the sickest patients and will now provide coverage of them regardless of the condition of infected patients’ livers. While Tuft’s belated change of heart under public pressure is nonetheless welcome, the Globe also noted that “[m]ost health insurers in Massachusetts have policies requiring evidence of advanced liver disease before they will pay for treatment. That includes the plans that enroll two-thirds of people in MassHealth, the state’s Medicaid program.”

In Michigan, the Harvard assessment showed that slightly more than half of plans place covered HIV medications on the highest cost-sharing tier. Most of these plans, such as Harbor Health Plan, Health Alliance, and Humana, require co-insurance rates of 50% for all covered HIV drugs. For hepatitis C patients, Health Alliance, Humana, and Physicians Health Plan charge 50% co-insurance, some of the highest in the nation. The full assessments for the 16 state Marketplaces which have been examined thus far may be found here.

In addition, a new study from Avalere, shows that some insurance plans are still placing all medicines for some conditions on the highest cost-sharing tier, despite warnings from CMS that this practice may be discriminatory.

Patients deserve access to the medicines their doctors determine are most suitable for their individual medical circumstances. Insurers and policymakers must keep pace with biomedical innovation by ensuring access to the latest medical breakthroughs for patients today and encouraging sustained innovation for those who will need it tomorrow.