*We are now well into the New Year. Many people have abandoned their New Year’s resolutions, and some probably can’t even remember theirs, but for many of my patients, the true significance of a new calendar year is their health insurance. Some patients have new insurance. Those that have the same insurance have to start all over again to meet their deductible, and some have to begin a new struggle to get financial assistance to pay for expensive biologic medications. Prices go up and up, and benefits shrink and sometimes vanish entirely, leaving doctors and patients to try and cope with a tremendous headache. Patients are caught between a cruel disease and miracle medications that are almost always out of their reach financially. This plight is summarized eloquently in an excerpt from a letter one of my patients recently sent me:
Dr. Greenbaum,
I thought I should tell you what is going on with my [biologic]. First, thank you for your help with the [biologic] foundation application. Unlike last year, they have not approved my application. ... The [biologic] has been a great help with my rheumatoid arthritis (RA) and I hope at some point in the near future to be able to continue using it. It is, however, very expensive even with Medicare Part D. It is so expensive that it would have a negative long-term impact on our long term financial situation. For this reason, I am continuing to seek financial assistance until all options are exhausted before I change the financial structure of our retirement. All this means that at present, I am not taking [my prescribed biologic]. ... I intend to maintain our relationship. I am working, hoping, and praying that during this difficult time I will not experience any setbacks or flares and that my efforts will prove successful. ...
The foundation is a nonprofit patient-assistance program that provides the biologic at no cost to qualifying patients with no or limited drug coverage." Unfortunately, patients need to renew their support every year, leaving patients to worry what they will do if they are not approved for additional coverage. When the foundation runs out of money, it is discouraging for patients who had done well on the biologic previously. Desperate patients look to their rheumatologist to pull off some therapeutic sleight of hand or to locate alternative drug company largesse.
That isn’t fair. With the money drug companies make off our patients and our prescriptions, I think they have a moral obligation to continue to assist every patient they have started to help, rather than create panic and havoc year after year.
Some patients try to be resourceful during these crises. A common coping strategy that many of my patients adopt is to stretch the dose interval of their medication. One of my patients with psoriatic arthritis stretched the normal 2-week interval of his biologic dosing to 3.5 weeks, or until his hands and feet started to hurt. I often remind patients that I am not endowed with x-ray vision, but you don’t have to be a genius to predict that stretching out doses is not going to do an optimal job of impeding the radiographic progression of their disease!
One of my other RA patients with commercial insurance has done very well on his biologic, but because of the inadequacy of his insurance benefits, he runs out of medication at the end of every calendar year, and then he has to either do the big stretch for a few months or subsist on samples that my office gives him when we have them. We both got sick of this, and I had the bright idea that I’d like to have him switch drugs to one of the new kids on the biologic block. The nurse went through the motions of checking his insurance coverage, and we got back a message that was both blunt and discouraging. Regardless of which biologic I prescribed, my patient would be responsible for 45% of the bill. With a price tag of about $25,000 a year, that was a complete conversation stopper.
Insurance companies are sometimes more willing to foot the bill for drugs given in the doctor’s office or an infusion clinic even though it is more expensive because of additional sizable clinic and administration fees. That mentality never made much sense to me. Why would insurance agree to pay extra for a patient to get the medication in my office but refuse to pay to have them use the medication at home?