Wall Street Journal - National Patient Advocate Foundation's Annual Capitol Hill Briefing Focuses on Patient Access Barriers to Life-Saving Medicines Placed on Specialty Tiers by Commercial Insurance Plans and Medicare

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The National Patient Advocate Foundation (NPAF) today convened a briefing on Capitol Hill to highlight the patient perspective on specialty tier prescription medicines and the barriers to their access for patients with cancer, multiple sclerosis, arthritis and other life-threatening and debilitating diseases. The medicines are some of the only therapies available to treat these conditions. The office of Congressman David McKinley (R-WV) and the Senate Finance Committee were represented at today's briefing to review legislative strategies to address specialty tiers in both commercial insurance plans and Medicare.

Many insurance plans, including Medicare Part D plans, place certain medications on a specialty tier, requiring patients to pay a percentage of the cost of the drug, which can be as high as 25-33%, as opposed to a fixed co-payment, resulting in high out-of-pocket costs. Specialty tiers were designed to control Medicare and commercial drug plan spending on prescription medications. However, these cost controls come with a high price tag for very sick patients.

"Specialty tier medications are very expensive therapies and attaching a large percentage to what I'm required to pay created a huge roadblock in my cancer treatment when I was prescribed a drug to aid in my chemotherapy," stated Glenda Chambers, a former breast cancer patient with a commercial insurance plan. "I was faced with a choice between my healthcare and financial future, a decision no cancer patient should ever be forced to make."

Categorizing certain medicines as "specialty tier drugs" and then requiring very sick people to pay a large percentage of the cost puts patients at risk of losing their lives or severely reducing their quality of life due to their inability to finance a significant part of their therapy. A 2010 study that appeared in the Journal of Managed Care Pharmacy found that oncology patients taking prescription medications with an out-of-pocket cost higher than $200 were at least three times more likely to choose not to fill their prescriptions as those with out-of-pocket costs of $100 or less.

Congressman David McKinley (R-WV), whose office was represented at the briefing, has put forth legislation to mitigate the numerous problems specialty tier drugs pose to patients. The Patient Access to Treatments Act (H.R. 460), co-sponsored by Representative Lois Capps (D-CA) and a bipartisan list of 38 other Members, aims to give millions of patients access to critical treatments that are currently out of their financial reach. Under this legislation, commercial insurers could not charge patients a percentage of the drug cost, but rather the same fixed co-payment they charge for other medications.

"A diagnosis of a debilitating disease is enough stress for patients and their families," McKinley stated. "Cutting-edge drug therapies should be made accessible to all patients regardless of their financial situation. The right to treatment and the highest quality of life possible while ill is not just for the wealthy."

NPAF has also developed a three-pronged strategy to combat the high out-of-pocket costs of specialty tiers. NPAF is working closely with Representative McKinley's office to increase awareness to H.R. 460 and with Senate staff to explore specialty tier solutions in Medicare. NPAF is also working with the Centers for Medicare and Medicaid Services to examine regulatory solutions to specialty tiers. Furthermore, NPAF is collaborating with the health insurance industry to create an open dialogue on solutions and agreements on specialty tiers outside the legislative and regulatory scope. By doing so, NPAF aims to understand the impact changes to health plan cost sharing would have on all commercial plan enrollees.

"The financial requirement attached to specialty tier medications puts curative therapies and a high quality of life out of reach for too many patients," added Nancy Davenport-Ennis, CEO and founder of the Patient Advocate Foundation (PAF). "We are urging Congress to recognize the barriers to access created by the current patient cost-sharing policy and enact legislation to ease the financial burden patients face. We stand ready to work with lawmakers on developing patient-centric policies."

The briefing concluded with the release of the Patient Advocate Foundation's annual Patient Data Analysis Report (PDAR). In 2012 PAF successfully resolved 109,147 cases and served patients with 309 different health conditions, an increase of 5.9% in patient volume since 2011. Beth Patterson, PAF President of Mission Delivery presented the data. Since its inception in 1996, PAF has successfully resolved hundreds of thousands of patient cases.

National Patient Advocate Foundation is a national non-profit organization providing the patient voice in improving access to, and reimbursement for, high-quality healthcare through regulatory and legislative reform at the state and federal levels. NPAF translates the experience of millions of patients who have been helped by our companion, Patient Advocate Foundation, which provides professional case management services to individuals facing barriers to healthcare access for chronic and disabling disease, medical debt crisis and employment-related issues at no cost.

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