Monday, April 9, 2018

Op-ed: Pharmacy benefit managers exclude diabetes medications and supplies from coverage more than any other category

As insurers continue to exclude many diabetes-related medications and supplies from coverage, children with diabetes could be "saddled with lifetimes of exorbitant out-of-pocket costs," Stewart Perry and Jeff Hitchcock write in an op-ed for the Lexington Herald-Leader.

Perry, of Lexington, is the parent of a child with diabetes and the past national chairman of the board of the American Diabetes Association. Hitchcock is founder and president of Children with Diabetes and a member of the Doctor-Patient Rights Project.

Kentucky ranks fifth among all states in the rate of diabetes, with over 13 percent of the state's adults diagnosed with the disease.

The authors say that the growing number of Kentuckians with diabetes could be one of the reasons pharmacy benefit managers -- who act as middlemen between patients and drug companies -- are excluding so many diabetes-related medications and supplies from being covered. They note that these exclusions are "more than any other treatment category."

Perry and Hitchcock write that a Doctor-Patient Rights Project study found that 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," they write.

The idea behind these exclusion lists is to compel patients to use less expensive treatment choices, "falsely assuming that every patient with diabetes will respond the same way to every treatment choice," the authors write. The study found that many patients who are 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.

The authors of the op-ed add that other studies show that when patients have to pay more for their medications, they are more likely take the drug incorrectly by splitting pills or skipping doses to make it last longer. They add, "forced non-medical switching may even backfire as a cost-saving strategy for insurers" because failure to use medication as prescribed makes treatment less effective.

Such failure "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," they write. "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."

Perry and Hitchcock say fully covering prescribed treatments would allow parents to use the most effective medications for their children, and allow the medications to be used appropriately. They conclude: "The cost savings generated by letting doctors drive treatment decisions more than compensates for the higher pharmaceutical costs."

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