The US healthcare system is challenged by high costs during this tough economic period. Decisions about how to rein in these costs will need to be made by insurers, employers, states and the federal government. It’s important to understand how they will affect people with bleeding disorders.
Healthcare costs continue to increase faster than inflation. Spending for specialty drugs, which include factor products, increased 19.6% in 2010, according to Express Scripts’ 2010 Drug Trend Report. For a family of four with a preferred provider plan (PPO) in 2011, total insurance premium and out-of-pocket costs were $19,393, a 7.3% increase over the previous year, according to the Milliman Medical Index. This index tracks healthcare costs annually using industry data and a survey of employers. Of the $19,393, the employer paid $11,385 for premiums, while the employee paid $8,008 ($4,728 for premiums and $3,289 in out-of-pocket costs).
The National Hemophilia Foundation’s (NHF’s) advocacy team is keeping on top of these changes and is in frequent contact with congressional staff in Washington, DC. It is important that you continue to share information about any differences in coverage you encounter with your hemophilia treatment center, or your access to factor products and home care companies.
[Steps for Living: What Influences Coverage]
Challenges to Healthcare Reform
The new federal healthcare reform law, known as the Affordable Care Act (ACA), is facing legal challenges. The law provides insurance protections, provisions to control healthcare costs and insurance purchase options for individuals and small employers (through insurance exchanges beginning in 2014). However, the constitutionality of the law is being challenged in several states. Opponents take issue with the provision requiring all individuals to purchase insurance, set to take effect in 2014.
Challenges are expected to reach the US Supreme Court. If the high court determines the law is unconstitutional, it will probably focus on only part of the law, likely involving the insurance requirement or “individual mandate,” not the entire law. The portions of the law that eliminate lifetime and annual limits, provide increased dependent coverage and limit pre-existing condition exclusions would probably remain in effect.
Insurance Cost Controls
Medicaid, Medicare, commercial health insurance providers and employers are trying to control rising healthcare costs by restricting insurance eligibility, reducing reimbursement, reducing benefits and increasing patient out-of-pocket costs.
These cost control measures come at a time of economic instability, which increases the potential that their number and level will be increased and put in place sooner. The uncertainty of the status of new healthcare reform makes this scenario even more complicated.
Impact on Patients With Bleeding Disorders
Health insurance premium costs and out-of-pocket costs keep increasing. For individuals with bleeding disorders, many of whom reach their out-of-pocket limits every year, higher out-of-pocket costs mean an even greater budget drain.
A big unknown for individuals with bleeding disorders is the extent to which insurers will manage factor products and factor product providers—the homecare companies. Extra pressure to manage factor product costs will come from a number of new recombinant and longer-lasting products scheduled to enter the marketplace in the next few years. (See “Treatment Breakthroughs.")
Insurance management of factor products can include prescription prior authorization requirements; prescription case management; restricted formularies (in which some factor products in a class of factor products are not covered); different drug tiers (or levels) of coverage for different factor products; and step therapy, in which a lower-priced factor product is required to be used and determined to be ineffective before a more expensive product can be prescribed.
Insurance management of factor product providers will focus on how many providers an insurer will approve and the price it will pay for each factor product. In the future, it is likely that insurers will approve fewer factor product providers, which limits patient choice, to control costs and maximize efficiencies.
“Understanding and evaluating your health plan options can be a difficult and tedious process. However, for those affected by a chronic condition, the decision about which health plan is most appropriate for your needs may be one of the most important decisions you make,” says Val Bias, NHF’s CEO. NHF has developed a Personal Health Insurance Toolkit to help guide you through the evaluation process. For a copy, go to www.hemophilia.org and click on the Health Plan Comparison Guide link in the Helping Consumers box.