Patients battling the toughest medical conditions often benefit the most from newer, innovative medications and procedures. But breakthrough treatments are increasingly excluded from insurance company formularies, forcing many patients to choose between ignoring debilitating symptoms or going bankrupt. Reasonable cost controls should not require insurers to sacrifice medical innovations for patients with few other choices.
I am alive today because of a medical procedure that was once considered cutting-edge and costs about $800,000. Due to an unfavorable gene mutation, I developed Acute Myeloid Leukemia, a relatively rare form of bone marrow cancer. New treatments made available in just the last five years saved my life. Today, patients can live decades with the disease because of pioneering advances in marrow transplantation and other treatments.
The transplant I underwent created a chronic condition in my lungs that I will have to treat for the rest of my life. But, with improved procedures – many of which were experimental and expensive initially – more patients like me are managing side effects that may not have been survivable just a few years ago.
Today, health insurers deny treatment coverage for almost a quarter of patients treating chronic or persistent conditions, according to a recent survey of insured patients. Many of those denials were because the prescribed treatment was placed on the insurer’s formulary exclusion list.
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Health insurance companies routinely issue formularies cataloguing the medications and procedures the insurer covers and at what level of reimbursement. Around 2011, one of the insurance industry’s largest pharmacy benefit managers (PBMs) also released a list of treatments that would explicitly would not be covered. CVS/Caremark’s initial list prompted other insurers (and other PBMs) to follow suit.
In the few years formulary exclusions have been in use, the number of excluded treatments listed has grown enormously. From CVS’s initial list of 37 medications, medical supplies and procedures it would not cover, its formulary exclusion list now names 154 excluded treatments. Since its first announced list in 2014, Express Script’s formulary exclusions have nearly tripled to 161 uncovered treatments.
Formulary exclusions started out as a way for health plans to leverage their enrollment numbers to manage soaring health-care costs. Insurers could negotiate lower costs for certain common treatments by compelling large groups of patients to switch to the cheaper options. But insurers are now expanding formulary exclusion lists not only to direct large patient groups, but to exclude the most expensive and innovative treatments that are the only effective options for smaller patient groups treating rare, debilitating diseases.
For example, newer, innovative diabetes medications constitute a significant number of the treatments listed on the formulary exclusion lists of the largest PBMs. With one in three U.S. adults expected to develop diabetes within their lifetimes, treating the disease represents a substantial, long-term expense for insurers. However, while there are more than a dozen different treatments for type 2 diabetes, they are mostly ineffective for a minority of patients who can only control their blood sugar levels with newer, innovative treatment options.
It seems reasonable that insurers would use formulary exclusions to direct typical diabetes patients to choose less expensive treatments among a number of suitable options. But, for a small number of patients, excluding these newer treatments can foreclose the only options that have proven effective for them.
All patients ultimately benefit from access to treatment innovations. The most common treatments were once costly breakthroughs. Liver transplantation was a promising, but expensive procedure when it was first successfully performed in the 1960s. Today, liver transplants have a success rate over 90 percent and they are routinely performed at over a hundred centers in the U.S.
Insurers that exclude coverage for the most advanced medications and procedures not only create barriers to care for some patients who need the newest treatments, they also expand the time it takes for experimental medical breakthrough to become commonplace treatments that save more lives and improve the standard of care for everyone.
Kevin LeCount is bone-marrow transplant recipient and leukemia survivor who lives in Raleigh.