Opinion
VIEWPOINT
Gregory J. Esper, MD, MBA Emory University School of Medicine, Atlanta, Georgia. Daniel Hartung, PharmD, MPH Oregon State University/Oregon Health & Science University College of Pharmacy, Portland. Orly Avitzur, MD, MBA New York Medical College, Valhalla.
Corresponding Author: Gregory J. Esper, MD, MBA, Brain Health Center, 12 Executive Park, Office 288, Atlanta, GA 30329 ([email protected]). jamaneurology.com
The Patient Protection and Affordable Care Act and Chronic Neurological Illnesses Benefits and Challenges The Patient Protection and Affordable Care Act (ACA) is the most sweeping attempt at establishing access to medical care for US citizens since the establishment of Medicare by the Centers for Medicare and Medicaid Services in 1965. Despite its polarizing political, social, and economic effects, many provisions of the ACA have been enacted sequentially since being signed into law in 2010. Provisions of the act effectively eliminated insurance denial for preexisting conditions, created cost-sharing limits for in-network care, and removed annual dollar limits on covered benefits. Certain essential health benefits standards are covered such as hospitalization, ambulatory care, and prescription drugs. All of these provide considerable advantages to patients for services that were not in place before the law was signed. Approximately one-third of nonelderly adults had difficulty paying medical bills in 2012. Bankruptcy is common due to the high costs of their medical bills; many people are forced to sell assets even to pay deductibles.1 One of the main goals of the ACA was to reduce such burdens on the underinsured and the uninsured. A major provision of the ACA that established the new health insurance exchange (HIX) marketplace went into effect across all 50 states in 2014. The HIX product offerings include 4 tiers (bronze, silver, gold, and platinum) supported by commercial insurers, state expansions of Medicaid, or federal supplements in states that did not expand Medicaid. Eight million people are now enrolled in an HIX plan, the majority choosing silver-level plans; estimates suggest the number of uninsured Americans had declined 3% to 5% as of March 2014.2 However, many plans require deductibles that are difficult to pay before insurance benefits begin. The median individual deductible is $2500 and the maximum is $6250, while the median drug deductible is $400 and the maximum is $2500.3 Payments for many of the plans also are remunerated somewhere between Medicaid and Medicare rates such that health care professionals and health systems are wary of accepting many of the HIX health plans, especially those with federal and stateexpanded Medicaid supplementation; this currently adversely affects access to care. There is also emerging evidence that some insurers are structuring drug benefit schemes to purposefully discourage high-cost patients from enrolling.4 Neurologists and other providers of neurologic care are specifically concerned about the effect of the ACA on access to care for neurologic disorders, which
are often chronic and require long-term treatment. Stroke affects nearly 800 000 people per year and more than 30% have some form of long-term disability after stroke.5 Approximately 5 million Americans have Alzheimer disease currently, with 14 million people projected to have it by 2050; yearly care costs range from $150 billion to $200 billion per year.6 Epilepsy, Parkinson disease, and migraine often result in disabilities that render many patients dependent in activities of daily living, unable to work and function within professional, social, and home-based settings. Consider, for example, a 27-year-old woman with multiple sclerosis who lives in Washington. Her average individual premium would be $244 per month with an in-network medical deductible of $2297; the average out-of-network deductible is $5000. The in-network drug deductible for many plans is classified as part of the medical deductible but can also range individually from $200 to $1000. Out-of-network drug costs range from $2500 to not covered, although the individual medical maximum out-of-pocket cost for any plan is $6350 per year. Patients are forced to choose between types of services such as imaging, drugs, or medical visits. This issue becomes increasingly more complex when affected patients require medications for chronic inflammatory diseases such as multiple sclerosis. The Table summarizes disease-modifying therapy drug benefits for a sample of HIX plans available in Washington by tier (median premium plan selected for each tier). For most plans, a 20% to 40% coinsurance would represent $700 to $1600 in monthly outof-pocket costs. Although the bronze plan covers 100% of costs after the $5250 deductible is reached, patients would need to pay nearly $4000 out of pocket for the first month of treatment and around $1000 for the next. For the woman described earlier, her neurologist may wish to prescribe certain oral disease-modifying therapies, but high deductibles or lack of coverage may limit use. For the silver plans, 4 of 7 DMTs either are not covered or would require her neurologist to submit a prior authorization for coverage. If her neurologist selected interferon beta-1a intramuscular injection (Avonex), the first month would cost her $2743 ($2500 deductible + 20% of remaining $1214) out of pocket in addition to her monthly premium of $238. Subsequent months would cost $743 until her maximum out-of-pocket cost of $4100 was reached. As HIX plans become more common, formal study of both access to care and access to the correct (Reprinted) JAMA Neurology July 2015 Volume 72, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 07/31/2015
739
Opinion Viewpoint
therapies is required. For individuals with chronic debilitating conditions such as multiple sclerosis, it is important that up-front
costs for accepted treatments are not overly burdensome for patients.
Table. Disease-Modifying Therapy Drug Benefits for a Sample of Health Insurance Exchange Plans Available in Washington by Tiera Variable
Bronze
Silver
Gold
Annual deductible, $
5250
2500
1000
250
Monthly premium, $
192
238
299
330
5250
4100
4500
2500
Interferon beta-1b ($3919)
Specialty pharmacy; 0% coinsurance; $0
Specialty pharmacy; 20% coinsurance; $784
Specialty pharmacy; 20% coinsurance; $784
Specialty pharmacy; PA; 40% coinsurance; $1568
Interferon beta-1a intramuscular injection ($3714)
Tier 2 (preferred brand); 0% coinsurance; $0
Tier 2 (preferred brand); 20% coinsurance; $743
Tier 2 (preferred brand); $40 copay
Specialty pharmacy; 40% coinsurance; $1486
Glatiramer acetate ($3612)
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; PA; nonpreferred brand; 20% coinsurance; $753
Specialty pharmacy; 40% coinsurance; $1445
Interferon beta-1a subcutaneous injection ($4027)
Specialty pharmacy; 0% coinsurance; $0
Specialty pharmacy; 20% coinsurance; $805
Specialty pharmacy; 20% coinsurance; $805
Specialty pharmacy; 40% coinsurance; $1611
Fingolimod ($3977)
Specialty pharmacy; PA; 0% coinsurance; $0
Specialty pharmacy; PA; 20% coinsurance; $795
Specialty pharmacy; PA; 20% coinsurance; $795
Specialty pharmacy; PA; 40% coinsurance; $1591
Teriflunomide ($3764)
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; PA; nonpreferred brand; 20% coinsurance; $753
Specialty pharmacy; PA; 40% coinsurance; $1506
Dimethyl fumarate ($4027)
Specialty pharmacy; PA; 0% coinsurance; $0
Specialty pharmacy; PA; 20% coinsurance; $805
Specialty pharmacy; PA; 20% coinsurance; $805
Not listed
Maximum out-of-pocket cost, $
Platinum
Medication (pharmacy acquisition cost)b
Abbreviation: PA, prior authorization required. a
Bronze plan example is the Premera Blue Cross Preferred Bronze 5250 health savings account; silver plan, Premera Blue Cross Preferred Silver 2500 health savings account; gold plan, Premera Blue Cross Preferred Gold 1000; and platinum plan, BridgeSpan Exchange Platinum High.
b
Acquisition cost is estimated by wholesale acquisition cost less Medicaid rebate of 23.1% of average manufacturer price. Plan pharmacy details are given along with out-of-pocket costs after the deductible is met.
ARTICLE INFORMATION Published Online: May 4, 2015. doi:10.1001/jamaneurol.2015.0273. Conflict of Interest Disclosures: Dr Avitzur reported serving as a medical adviser at Consumer Reports. No other disclosures were reported. REFERENCES 1. Pollitz K, Cox C, Lucia K, et al. Medical debt among people with health insurance. https: //kaiserfamilyfoundation.files.wordpress.com/2014 /01/8537-medical-debt-among-people-with -health-insurance.pdf. Accessed January 30, 2015.
740
2. Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services. Health Insurance Marketplace: summary enrollment report for the initial annual open enrollment period. http://aspe.hhs.gov/health /reports/2014/marketplaceenrollment/apr2014/ib _2014apr_enrollment.pdf. Accessed January 30, 2015. 3. Breakaway Policy Strategies; Robert Wood Johnson Foundation. Eight million and counting: a deeper look at premiums, cost sharing and benefit design in the new health insurance marketplaces. http://www.rwjf.org/content/dam/farm/reports /issue_briefs/2014/rwjf412878. Accessed January 30, 2015.
4. Jacobs DB, Sommers BD. Using drugs to discriminate: adverse selection in the insurance marketplace. N Engl J Med. 2015;372(5):399-402. 5. Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics: 2015 update: a report from the American Heart Association. Circulation. 2015;131 (4):e29-e322. 6. Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med. 2013;368(14):1326-1334.
JAMA Neurology July 2015 Volume 72, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 07/31/2015
jamaneurology.com
VIEWPOINT
Gregory J. Esper, MD, MBA Emory University School of Medicine, Atlanta, Georgia. Daniel Hartung, PharmD, MPH Oregon State University/Oregon Health & Science University College of Pharmacy, Portland. Orly Avitzur, MD, MBA New York Medical College, Valhalla.
Corresponding Author: Gregory J. Esper, MD, MBA, Brain Health Center, 12 Executive Park, Office 288, Atlanta, GA 30329 ([email protected]). jamaneurology.com
The Patient Protection and Affordable Care Act and Chronic Neurological Illnesses Benefits and Challenges The Patient Protection and Affordable Care Act (ACA) is the most sweeping attempt at establishing access to medical care for US citizens since the establishment of Medicare by the Centers for Medicare and Medicaid Services in 1965. Despite its polarizing political, social, and economic effects, many provisions of the ACA have been enacted sequentially since being signed into law in 2010. Provisions of the act effectively eliminated insurance denial for preexisting conditions, created cost-sharing limits for in-network care, and removed annual dollar limits on covered benefits. Certain essential health benefits standards are covered such as hospitalization, ambulatory care, and prescription drugs. All of these provide considerable advantages to patients for services that were not in place before the law was signed. Approximately one-third of nonelderly adults had difficulty paying medical bills in 2012. Bankruptcy is common due to the high costs of their medical bills; many people are forced to sell assets even to pay deductibles.1 One of the main goals of the ACA was to reduce such burdens on the underinsured and the uninsured. A major provision of the ACA that established the new health insurance exchange (HIX) marketplace went into effect across all 50 states in 2014. The HIX product offerings include 4 tiers (bronze, silver, gold, and platinum) supported by commercial insurers, state expansions of Medicaid, or federal supplements in states that did not expand Medicaid. Eight million people are now enrolled in an HIX plan, the majority choosing silver-level plans; estimates suggest the number of uninsured Americans had declined 3% to 5% as of March 2014.2 However, many plans require deductibles that are difficult to pay before insurance benefits begin. The median individual deductible is $2500 and the maximum is $6250, while the median drug deductible is $400 and the maximum is $2500.3 Payments for many of the plans also are remunerated somewhere between Medicaid and Medicare rates such that health care professionals and health systems are wary of accepting many of the HIX health plans, especially those with federal and stateexpanded Medicaid supplementation; this currently adversely affects access to care. There is also emerging evidence that some insurers are structuring drug benefit schemes to purposefully discourage high-cost patients from enrolling.4 Neurologists and other providers of neurologic care are specifically concerned about the effect of the ACA on access to care for neurologic disorders, which
are often chronic and require long-term treatment. Stroke affects nearly 800 000 people per year and more than 30% have some form of long-term disability after stroke.5 Approximately 5 million Americans have Alzheimer disease currently, with 14 million people projected to have it by 2050; yearly care costs range from $150 billion to $200 billion per year.6 Epilepsy, Parkinson disease, and migraine often result in disabilities that render many patients dependent in activities of daily living, unable to work and function within professional, social, and home-based settings. Consider, for example, a 27-year-old woman with multiple sclerosis who lives in Washington. Her average individual premium would be $244 per month with an in-network medical deductible of $2297; the average out-of-network deductible is $5000. The in-network drug deductible for many plans is classified as part of the medical deductible but can also range individually from $200 to $1000. Out-of-network drug costs range from $2500 to not covered, although the individual medical maximum out-of-pocket cost for any plan is $6350 per year. Patients are forced to choose between types of services such as imaging, drugs, or medical visits. This issue becomes increasingly more complex when affected patients require medications for chronic inflammatory diseases such as multiple sclerosis. The Table summarizes disease-modifying therapy drug benefits for a sample of HIX plans available in Washington by tier (median premium plan selected for each tier). For most plans, a 20% to 40% coinsurance would represent $700 to $1600 in monthly outof-pocket costs. Although the bronze plan covers 100% of costs after the $5250 deductible is reached, patients would need to pay nearly $4000 out of pocket for the first month of treatment and around $1000 for the next. For the woman described earlier, her neurologist may wish to prescribe certain oral disease-modifying therapies, but high deductibles or lack of coverage may limit use. For the silver plans, 4 of 7 DMTs either are not covered or would require her neurologist to submit a prior authorization for coverage. If her neurologist selected interferon beta-1a intramuscular injection (Avonex), the first month would cost her $2743 ($2500 deductible + 20% of remaining $1214) out of pocket in addition to her monthly premium of $238. Subsequent months would cost $743 until her maximum out-of-pocket cost of $4100 was reached. As HIX plans become more common, formal study of both access to care and access to the correct (Reprinted) JAMA Neurology July 2015 Volume 72, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 07/31/2015
739
Opinion Viewpoint
therapies is required. For individuals with chronic debilitating conditions such as multiple sclerosis, it is important that up-front
costs for accepted treatments are not overly burdensome for patients.
Table. Disease-Modifying Therapy Drug Benefits for a Sample of Health Insurance Exchange Plans Available in Washington by Tiera Variable
Bronze
Silver
Gold
Annual deductible, $
5250
2500
1000
250
Monthly premium, $
192
238
299
330
5250
4100
4500
2500
Interferon beta-1b ($3919)
Specialty pharmacy; 0% coinsurance; $0
Specialty pharmacy; 20% coinsurance; $784
Specialty pharmacy; 20% coinsurance; $784
Specialty pharmacy; PA; 40% coinsurance; $1568
Interferon beta-1a intramuscular injection ($3714)
Tier 2 (preferred brand); 0% coinsurance; $0
Tier 2 (preferred brand); 20% coinsurance; $743
Tier 2 (preferred brand); $40 copay
Specialty pharmacy; 40% coinsurance; $1486
Glatiramer acetate ($3612)
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; PA; nonpreferred brand; 20% coinsurance; $753
Specialty pharmacy; 40% coinsurance; $1445
Interferon beta-1a subcutaneous injection ($4027)
Specialty pharmacy; 0% coinsurance; $0
Specialty pharmacy; 20% coinsurance; $805
Specialty pharmacy; 20% coinsurance; $805
Specialty pharmacy; 40% coinsurance; $1611
Fingolimod ($3977)
Specialty pharmacy; PA; 0% coinsurance; $0
Specialty pharmacy; PA; 20% coinsurance; $795
Specialty pharmacy; PA; 20% coinsurance; $795
Specialty pharmacy; PA; 40% coinsurance; $1591
Teriflunomide ($3764)
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; nonpreferred brand; not covered
Specialty pharmacy; PA; nonpreferred brand; 20% coinsurance; $753
Specialty pharmacy; PA; 40% coinsurance; $1506
Dimethyl fumarate ($4027)
Specialty pharmacy; PA; 0% coinsurance; $0
Specialty pharmacy; PA; 20% coinsurance; $805
Specialty pharmacy; PA; 20% coinsurance; $805
Not listed
Maximum out-of-pocket cost, $
Platinum
Medication (pharmacy acquisition cost)b
Abbreviation: PA, prior authorization required. a
Bronze plan example is the Premera Blue Cross Preferred Bronze 5250 health savings account; silver plan, Premera Blue Cross Preferred Silver 2500 health savings account; gold plan, Premera Blue Cross Preferred Gold 1000; and platinum plan, BridgeSpan Exchange Platinum High.
b
Acquisition cost is estimated by wholesale acquisition cost less Medicaid rebate of 23.1% of average manufacturer price. Plan pharmacy details are given along with out-of-pocket costs after the deductible is met.
ARTICLE INFORMATION Published Online: May 4, 2015. doi:10.1001/jamaneurol.2015.0273. Conflict of Interest Disclosures: Dr Avitzur reported serving as a medical adviser at Consumer Reports. No other disclosures were reported. REFERENCES 1. Pollitz K, Cox C, Lucia K, et al. Medical debt among people with health insurance. https: //kaiserfamilyfoundation.files.wordpress.com/2014 /01/8537-medical-debt-among-people-with -health-insurance.pdf. Accessed January 30, 2015.
740
2. Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services. Health Insurance Marketplace: summary enrollment report for the initial annual open enrollment period. http://aspe.hhs.gov/health /reports/2014/marketplaceenrollment/apr2014/ib _2014apr_enrollment.pdf. Accessed January 30, 2015. 3. Breakaway Policy Strategies; Robert Wood Johnson Foundation. Eight million and counting: a deeper look at premiums, cost sharing and benefit design in the new health insurance marketplaces. http://www.rwjf.org/content/dam/farm/reports /issue_briefs/2014/rwjf412878. Accessed January 30, 2015.
4. Jacobs DB, Sommers BD. Using drugs to discriminate: adverse selection in the insurance marketplace. N Engl J Med. 2015;372(5):399-402. 5. Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics: 2015 update: a report from the American Heart Association. Circulation. 2015;131 (4):e29-e322. 6. Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med. 2013;368(14):1326-1334.
JAMA Neurology July 2015 Volume 72, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 07/31/2015
jamaneurology.com
