Children ~ when pharmacy management cut benefits: echo from West Virginia

"Big pharma" is an euphemism for "Big profits", at the expense of quality patient care.

Diabetes insulin

In other words, when pharmacy management programs cut particular drugs our of their formulary lists (meaning the medicine is not covered), the result is that patients must either pay the price gouging costs or suffer the health  consequences. In the situations where children with diabetes cannot obtain their pharmacy needs through their insurance plans, either via Medicaid or private coverage, the problem can lead to preventable chronic health diseases or even early death.  Although this "echo", editorial published in the West Virginia Gazette Mail newspaper and blogged by me, the opinion describes the situation in the Mountain State and the price gouging, in fact, is also going on in other states.

Children pay when insurers cut diabetes coverage

Children with diabetes face a lifetime of challenges. 

However, if insurers continue to exclude more and more diabetes-related medications and supplies from coverage, those children and their families could be saddled with a lifetime of exorbitant out-of-pocket costs as well.

West Virginia’s rate of diabetes has steadily increased. More than 15 percent of West Virginians have been diagnosed with the disease, the highest rate among all states.

The growing incidence of diabetes may be one reason pharmacy benefit managers (PBMs) — the private companies health plans hire to oversee their prescription drug benefits — consistently exclude diabetes-related medications and supplies from coverage, more than any other treatment category. That’s according to a study by the Doctor-Patient Rights Project, which analyzed the increasing use of formulary exclusion lists, the catalogs PBMs issue to lay out the medicines they will no longer cover.

In the last four years, the number of diabetes-related medications or supplies excluded from coverage by the nation’s two largest PBMs (CVS and Express Scripts) has increased by almost 80 percent, the only treatment category where the PBMs consistently increased the number of excluded medicines every year. Diabetes-related treatments now account for one out of every five medicines excluded from coverage by these PBMs.

PBMs use formulary exclusion lists to compel patients to choose less-expensive treatment, falsely assuming that every diabetes patient will respond the same way to every treatment. They are a form of forced, nonmedical switching designed to save the insurer from having to pay for treatments chosen by the patient and physician.

The Doctor-Patient Rights Project found that many patients asked to switch to a new medication choose to pay out-of-pocket for the treatment their doctor originally prescribed, rather than switch to the insurer’s preferred drug. In effect, formulary exclusions simply transfer more of the cost of prescribed treatments to patients and their families.

Studies show that patients forced to shoulder more of the expense of their medications are more likely to try to make the prescriptions for their original medication last longer by splitting pills or skipping doses of insulin.

People with diabetes who do not experience immediate symptoms from not following proper treatment protocols may wrongly conclude that the medicine remains just as effective or that they need less of it. This is especially true of low-income and minority patients, who are already more likely to develop diabetes and to experience diabetes-related organ failure.

All parents want the best for their child, including the medicine the doctor believes will best care for their child’s diabetes. 

Insurers that refuse to cover certain prescribed diabetes treatments, thinking that parents will simply switch to the insurer’s cheaper alternative, may be gravely mistaken. Forced nonmedical switching may simply increase out-of-pocket expenses for parents, and, as a result, increase the lifetime treatment costs for their children with diabetes.

Forced nonmedical switching may even backfire as a cost-saving strategy for insurers. When patients fail to adhere to proper medication protocols, they make treatment less and less effective.

Reduced adherence, in fact, accounts for up to 10 percent of hospitalizations, 25 percent of nursing home admissions and as many as 125,000 premature deaths annually, according to a study in the Journal of Managed Care & Specialty Pharmacy. 

As a result, it contributes an extra $100 billion to $289 billion in medical expenses each year, at least some of which fall to insurers to pay.

Insurers that target diabetes-related medications and supplies for exclusion are being short-sighted.

When they fully cover prescribed treatments, insurers permit parents to start their children on the most effective medications and to use them appropriately. As a result, they experience improved clinical outcomes and fewer lifetime medical costs. The money saved by letting doctors drive treatment decisions more than compensates for the higher pharmaceutical costs.

This opinion was authored by Jeff Hitchcock, the founder and president of Children with Diabetes, one of the most established and well-trafficked online diabetes communities, and a member of the Doctor-Patient Rights Project. 

Stewart Perry is the past national chairman of the board of the American Diabetes Association, and the parent of a child with diabetes.