Patient Advocates Want Insurers to Offer Health Plans with Predictable Costs

Patient advocates have put forth a proposal that would require health insurers on the insurance exchange and in the employer market to design at least a quarter of their health plans to use only predictable copayments for prescription drugs rather than requiring consumers to pay coinsurance or face a deductible first.

Coinsurance costs can be utterly capricious since they are based on a percentage of the cost of a medication, procedure or office visit, a price that may vary over time.

Senate Bill 237 requires that 25 percent of plans offered use only fixed copayment amounts for cost sharing.

Copayment-only plans are a popular concept with consumers and were promoted by the now-defunct Oregon’s Health CO-OP. The CO-OP eventually became insolvent, but that was due to the federal government reneging on an expected $5 million in risk corridor payments for taking on sicker people who had been previously uninsured.

SB 237 applies only to medications, which can often cost consumers thousands of dollars if their plan has a high deductible or a coinsurance formula.

“Oregon has some of the highest co-insurance rates in the country, sometimes as high as 50 percent,” said Thea Zajac, the regional director of the Leukemia & Lymphoma Society.

Zajac argued that flat-dollar amounts that are reasonably graduated and apply toward the plan’s deductible are a much fairer way to make the patient share in drug costs. “It allows consumers to have a better idea of what they’re paying.”

She said Colorado and Montana have already passed laws requiring some health plans to use only copayments for cost sharing.

Peter Parisot of the Cascade AIDS Project said that sky-high coinsurance for people with HIV was causing them to fall off their medications, preventing Oregon from defeating the epidemic.

“This is a public health issue,” Parisot argued, noting that with anti-viral drug adherence, “They’ll be 97 percent less likely to spread the disease.”

Predictably, Elise Brown of America’s Health Insurance Plans and Tom Holt of Regence BlueCross BlueShield both spoke against SB 237, arguing that it would drive up premiums and mask the true cost of the drugs by passing them on to other consumers.

“The balloon is going to pop out somewhere,” Holt said. “It would insulate drug companies from the one thing that they fear most -- consumer pressure.”

Perhaps critically, the bill stops insurers from placing high-cost drugs in the high-cost copayment tier if it’s the only drug to treat an illness -- which are exactly the conditions that make some blockbuster drugs so expensive in the first place.

“People need to ask: Why do the drugs need to cost so much money?” argued Brown.

Regence is backing legislation from Rep. Rob Nosse, D-Portland, and Oregonians for Affordable Drug Prices, a comprehensive effort that limits the amount insurers can charge consumers out-of-pocket, but also gives health insurers a rebate on excessive costs.

Patient advocacy groups, which often rely on funding from pharmaceutical companies, were part of a task force that led to the Nosse legislation, but they have generally not been supportive of the compromise bill.

However, Basic Rights Oregon, the Oregon State Public Interest Research Group and Health Care for All Oregon are supporting Nosse, along with much of the state’s health insurance industry, the hospital industry, and unions representing public employees and healthcare workers.

While the House Health Committee has focused on a single bill, the Senate has taken the opposite approach, with as many as 10 competing bills under consideration that deal with the high cost of prescription drugs.

The Senate Health Committee has considered bills such as a rebate program similar to Nosse’s legislation as well as bills like SB 237 that leave the pharmaceutical industry harmless while hitting the health insurance industry for practices that are unfair to consumers, such as putting them through step-therapy protocols even when patients are already stable on a preferred drug.

Sen. Laurie Monnes Anderson, D-Gresham, has asked Sen. Jeff Kruse, R-Roseburg, and Sen. Elizabeth Steiner Hayward, D-Beaverton to combine these measures into some sort of compromise. But given the inability of Nosse to find consensus with Republicans such as Rep. Bill Kennemer of Canby, despite months on this issue, the two of them may be unlikely to forge a last-minute agreement in the Senate.

Chris can be reached at [email protected].