General Assembly Should Help Ohio Patients by Ending User Fee Manipulation for Expensive Treatments: Elisabeth S. Roter

CLEVELAND, Ohio — About 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 prevents thousands of Ohioans from being able to afford the drugs that can help relieve their pain.

There is no cure for arthritic diseases such as rheumatoid or psoriatic arthritis and others, but early treatment and lifestyle changes including changes in diet, exercise, surgery and medications, can reduce movement limitations and joint damage. Milder cases of arthritis are often treated with over-the-counter medications such as acetaminophen or NSAIDs and help relieve pain and inflammation.

Patients living with more severe cases of arthritis are often prescribed stronger and much more expensive drugs called biologics. These types of drugs are created from living sources and are more complex than other drugs. Biosimilars are the generic forms of biologics and although they are less expensive, they are still expensive.

To offset the cost of drugs, patients on high-deductible health plans have relied on third-party assistance, which could be from a drug manufacturer or a charitable foundation. However, health insurers and pharmacy benefit managers (PBMs are the middleman in the drug supply chain) have recently implemented policies they call co-pay accumulators that prevent patients from benefiting assistance.

Dr. Elisabeth S. Roter, president of the Ohio Association of Rheumatology, practices medicine with the teaching hospital system.

Insurers “accumulate” the financial assistance the patient receives, but do not apply the funds to patient disbursements such as their deductible or co-payment. Once a patient’s assistance runs out, they require the patient to pay their full deductible to access their medications.

Insurers do not return the assistance to the entity that provided the support, nor assist the patient. They double and add to their profits, all at the expense of the patient.

This cost-shifting practice to the patient now occurs at nine of Ohio’s 10 health plans and unfairly targets patients who need expensive drugs to treat conditions including arthritis, multiple sclerosis, cancer and thousands of rare diseases. Almost all (99.6%) of the financial assistance for drugs is currently used for drugs for which there are no generic equivalents.

Worse still, co-pay hoarders hurt patients who need help the most. Nearly 70% of patients dependent on third party assistance earn less than $40,000 per year.

As a provider, I see patients every day trying to manage their disease but struggling with the financial implications. Today, many never reach their deductible and delay and sometimes stop their care and treatment. For my arthritis patients, this results in flare-ups that, in addition to causing permanent joint damage, result in even more financially burdensome treatment for them, their families, 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 drug is available. It was unanimously rejected by the House, 86 to 0, and is awaiting review by the Ohio Senate Health Committee.

Sixteen other states and Puerto Rico have passed laws prohibiting these policies or regulating their use. 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 drugs by ensuring their state-regulated health plan applies any form of patient financial assistance towards their cost-sharing limits. On behalf of Ohio’s rheumatology providers and the tens of thousands of patients we care for, I encourage members of the Ohio Senate to vote yes for Bill 135.

Dr. Elisabeth S. Roter, president of the Ohio Association of Rheumatology, practices medicine with the teaching hospital system.

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