Transcript Powerpoint

Approaches to Helping the Under-Insured
September 2008
Agenda
Sharing Perspectives on Helping the Under-Insured:
• A Patient
• A Co-Pay Assistance Non-Profit
• An Insurance Company
• A Physician
• A Pharmacist
• Questions?
Page 2
A Patient’s Perspective
Judy Hodges
Breast Cancer Patient
Page 3
A Patient’s Perspective
“I sat in the oncologist’s office and kept saying, I
don’t have the money , but I’m not going to die
because I can’t pay for this. I am not going to die
because I am underinsured.”
Judy Hodges, PAN Patient
Page 4
A Non-Profit Perspective
Julie Reynes
President
Patient Access Network Foundation
Page 5
Why Co-Payment Assistance?
Consumer Share of Medical Costs: 2007 - 2008
30.0%
Percent Paid in Co-Payments
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Inpatient
Outpatient
Physician
Pharmacy
Component of Medical Care
Other
Pharmacy cost trends upward exceeded all other components
of medical care from 2007 - 2008.
Source: 2008 Milliman Medical Index
Page 6
Why Co-Payment Assistance?
• Prescription drugs have the largest co-payments
• Prescription drug costs are estimated to continue
increasing in the near term
• Physicians and hospitals have the flexibility to reduce or
waive their fees for lower income patients
• If a patient can obtain the thousands of dollars it may cost
to access their medications, they will be more likely to get
treatment
‘We found that reductions in drug copayments increased medical
adherence.’ Michael E. Chernew, Health Affairs, Jan-Feb 2008
Source: 2008 Milliman Medical Index
Page 7
Patient Access Network
• A 501(c)(3) public charity that launched our initial assistance program
in October, 2004.
• Currently supports 20 disease-state funds for oncology and chronic
diseases.
• Provides co-pay assistance of from $1500 - $7500 per year for
medications.
• Received favorable advisory opinion from the Office of the Inspector
General (OIG) of the Department of Health and Human Services in
December 2007.
• Have approved nearly 50,000 patients for cost-sharing assistance.
Dedicated to improving access to needed health services for
insured patients who cannot afford the out-of-pocket costs
associated with their treatment.
Page 8
The Need for Co-pay Assistance
from PAN is Increasing
Patients Approved
25,000
20,000
15,000
10,000
Funds Disbursed
5,000
2004
2005
2006
2007
$35,000,000
Projected
2008
2008
$30,000,000
$25,000,000
Demand is
increasing by over
30% each year,
while revenues
remain stable
$20,000,000
$15,000,000
$10,000,000
$5,000,000
$2004
Source: Patient Access Network Data, 2004 - 2007
Page 9
2005
2006
2007
Projected
2008
An Insurance Company’s
Perspective
Gary Owens
Physician and Consultant
Providing the Insurance Company’s Perspective
Page 10
Biotech Drugs as a Growth Area
Biotech Drugs in Development
Source: BCBSA Medical Cost Trend Report 2007
Biotech Drugs as a Growth Area
Biotech Drug Spending
Sources: CMS National Healthcare Expenditure Projection 2003-2013
What Does This Mean to a Plan?
• In 2007 Specialty Pharmacy spend was approximately
11.4% of total pharmacy spend (and was over 1/3 of
the total trend driver)
• The year over year specialty trend was 12.3%
• Unit cost was responsible for 8.4% with utilization
making up the other 3.9%
• Top three categories of specialty drug spending:
– Autoimmune diseases (Rheumatoid arthritis, Psoriasis, Lupus)
– Cancer
– Multiple sclerosis
13
Biotech Drugs and the
Health Plan
• Health plans recognize that new drugs and new uses of
existing drugs are creating revolutionary treatment
advances.
• Coverage of drugs is essential and important for any health
benefit plan.
• Purchasers are looking to plans to manage costs or pass
excess cost on to the consumer
• Balancing the need of the purchaser with the needs of the
consumer is difficult
• Not creating access problems for members is important.
• But so is keeping the plans affordable.
Disease Specific Examples
of Drug Cost
Chronic Condition
Medication Examples
Estimated
Cost/year
Hepatitis C
Pegasys, Peg-Intron, Infergen
$30,000
Multiple Sclerosis
Betaseron, Avonex, Copaxone
$12,000-$15000
Breast Cancer
Docetaxel, Adriamycin, Herceptin,
Tykerb
$12,000-$50,000
Non-Small Cell
Lung Cancer
Docetaxel, Carboplatin, Avastin
$20,000-$60,000
Rheumatoid
Arthritis
Enbrel, Remicaid, Humira, Kineret,
Rituxan
$15,000-$20,000
Pulmonary
Hypertension
Flolan, Tracleer, Remodulen
$65,000-$100,000
Guacher’s Disease
Cerezume, Zavesca
$150,000-$250,000
Sources: 2008 Medco Drug Trend Report, Specialty
Pharmacy News, October 2006
15
The Issues for Plans
• As cost of therapy increase, the cost of providing care
also increases
• With purchasers pressure on controlling costs, plans
have looked for new ways to involve patients in the
management of costs.
• However increasing co-payments and moving drugs
to co-insurance tiers have brought about access issues
for some patients
• Plans increasingly look to external resources to assist
members get access to care
Page 16
Plan Assistance to Members
• Plans provide case managers to work with patients
• These case managers can do any or all of the following:
– Educate members about the medication and the need for
compliance
– Help the patient access benefits in the most cost effective way
– Help the patient discuss treatment options with their physicians
and perhaps find less costly, yet clinically effective treatments
– Help the patients locate sources of financial assistance
– Inform physicians of plan benefits and options for members.
• Remember, we are all in this together and the goal of
patients, physicians and plans is to provide access to
high quality, yet affordable care.
17
A Physician’s Perspective
Allan B. Goldstein, MD
Physician and Consultant
Page 18
The Problem of Financial
Barriers
Office Visit Co-Pay
• $30 – 50 out-of-pocket for each office visit
• For weekly visits, $120-200 per month, $1,500-2,600 per yr
Oral Medication Co-Pay
• Higher co-pay for brand (tier 2) and non-preferred (tier 3)
meds
Parenteral Biologics
• Increasingly subject to 20% co-insurance (tier 4)
• Yearly costs for biologics may reach $100,000 or more
• Co-insurance may be $20,000+ per year
Page 19
Medicare Prescription Drug
Coverage (Part D)
• Premium: $0-100+ per month
• Deductible: $275 per year
• Coinsurance: $559 (25% of first $2,510)
• “Donut Hole”: $3,216 (no coverage $2,510 to $5,726)
• Total Out-of-Pocket $4,050 excludes monthly premium
• “Catastrophic” Coverage: patient pays 5% of any
expenses over $5,726
Total Out-of-Pocket = Lots!
Page 20
The Scope of the Problem
Some Specialties Impacted:
Endocrinology
Gastroenterology
Hematology
Neurology
Oncology
Pediatrics
Pulmonology
Rheumatology
Page 21
The Scope of the Problem
Some Diagnoses Impacted:
Anemia
Breast Cancer
Colorectal Cancer
Cutaneous T-Cell Lymphoma
Lung Cancer
Multiple Myeloma
Myelodysplastic Syndrome
Non-Hodgkin’s Lymphoma
Pancreatic Cancer
Rheumatoid Arthritis
Psoriatic Arthritis
Ankylosing Spondylitis
Crohn’s Disease
Cystic Fibrosis
Multiple Sclerosis
Gaucher’s disease
Growth Hormone Deficiency
Page 22
Physician Responses
• Absorb the co-pay
• Collect the co-pay up front
• Refer to hospital or clinic
• Stop providing infusion services in the office
• Employ sub-optimal treatment regimen
• Hire staff to conduct financial evaluation
• Identify and counsel patients unable to meet outof-pocket requirements
Page 23
Consequences for Patients
• Disruption of the patient/physician relationship
• Increased travel and inconvenience
• Financial stress or distress
• Failure to take medications
• Sub-optimal treatment
• Clinical deterioration and/or disease process progression
The underinsurance challenges may negatively
impact the patient’s health.
Page 24
A Pharmacist’s Perspective
Edith Rosato, PharmD
Senior Vice President, Pharmacy Affairs
and National Association of Chain Drug Stores
Foundation
Page 25
National Spending on Healthcare
Cost increases for hospital outpatient services and prescription drugs continue
to outpace those for inpatient and physician services.
Annual Per Capita Percentage Change in Health Care Spending, by Category of Service, 2001-2006
Source: Bradley C. Strunk, Paul B. Ginsburg, and John P. Cookson. "Tracking Health Care Costs:
Declining Growth Trend Pauses In 2004." Health Affairs Web Exclusive, June 21, 2005; and Ginsburg,
Paul B., Bradley C. Strunk, Michelle I. Banker, and John P. Cookson. "Tracking Health Care Costs:
Continued Stability But At High Rates In 2005." Health Affairs Web Exclusive, Oct. 3, 2006.
The Underinsured:
Coping With Rising Prescription Drug Costs
• Represent 25M in 2007 and rising
• 72M or 41% of working-age adults have problems paying
medical bills
– 29% unable to pay for basic necessities
– 39% use savings
– 30% take on credit card debt
• 46% skimp on medications
• 33% compared to 19% of adequately insured used ER
• The uninsured population compounds this issue
Sources: The Commonwealth Fund, Biennial Health Insurance Surveys, August 2008
The Current State of Medication
Adherence in the U.S.
•
Estimated annual costs to the healthcare system: $177B
•
Only 50% of patients take medications as prescribed
•
Reasons for non-compliance:
– Cost
– Forgetfulness
– Denial of the illness
– Misunderstanding of the directions
– Lack of understanding of the disease
– Lack of symptoms
•
Impact of chronic disease:
– 130M patients (45% of population); 7-10 deaths annually
– $1.3 Trillion annual drag on economy
– Represents 91% of all prescriptions filled
The Result is a
Significant Public Health Crisis
Sources: National Council on Patient Information and Education, “Enhancing Prescription Medicine
Adherence: A National Action Plan”. August 2007
Community Pharmacy Response
• Many chains have introduced prescription savings
programs to assist the uninsured or underinsured
• Covers prescription brand and generic drugs,
preventative and lifestyle drugs, vision, dental and
hearing…even pet meds
Other Discounted Drug Programs and
Financial Assistance Programs
HealthCare Club of America
Retail Clinics
• Health and wellness destination
• Offers affordable healthcare
• One-stop shopping convenience
Government Programs
• Health Resource Services Administration 340B Program
– Safety Net Clinics
• Medicare Part D: Covering the “donut hole” patients
• SCHIP: America’s Promise Alliance and All Kids
Covered
Healthcare Reform Debate:
Opportunity to Advocate for Patients
• High quality, affordable and accessible healthcare
coverage should be the goal of any reform proposal
• Cost-sharing, such as patient co-pays, should be set at
affordable levels and not prevent patients from seeking
appropriate medical care
• Patients should have access to the most cost-effective
medication to treat their condition
• Lower cost, equally effective generic medications
should be encouraged
• Preventative services such as medication therapy
management should be encouraged
Role of the Pharmacist
• Convenient, highly accessible community based health
resource for patients
• Pharmacists are knowledgeable about available
programs for uninsured and underinsured patients
• Encourage patients to utilize and interact with their
pharmacists
Conclusions
• Patients are making life or death decisions based on
their ability to pay for healthcare
• Each healthcare component is trying to help in its own
way
• Medication costs are a large component of the
challenge.
• Each healthcare component has constraints imposed
by the government, stockholders, funding, etc.
• Many challenges remain
• Healthcare reform is likely to create new challenges
Questions?
Page 35