Other Voices

Leave health care decisions to patient and doctor, not cost-cutting insurance industry

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If your child gets sick, who do you want to be in charge of choosing a treatment to make your young one better? Your choices are your doctor or your insurance company.

I think all Texans would agree that we want our doctors to help us make health care decisions. This is why all Texans should strongly encourage their state legislators to support pending legislation that would rein in non-medical switching.

As a child neurologist, I care for children with chronic neurological conditions such as autism, epilepsy, and ADHD. Often times I go through a lengthy process with my patients, considering genetics, epigenetics, and other biopsychosocial factors to find pharmaceutical treatments that effectively control their symptoms. When non-medical switching suddenly takes those medications away, they are back at square one, trying to find a new treatment that works for them.

Non-medical switching is an insurance industry cost-cutting tactic. It happens when an insurer or a pharmacy benefit manager forces a stable patient into switching from an effective, doctor-prescribed medication to a different, plan-preferred drug. The insurance company is basically guessing that the other medicine they give you will work just as well.

Sometimes there is no equally effective alternative. This can lead to symptoms recurrence, the emergence of new side effects or the loss of control of a previously well-managed illness. A young child with controlled ADHD can suffer from lapses in attention and have their academics suffer. An epileptic adult may even lose driving privileges if their seizures lose control!

How can an insurance company do this? They create barriers of access to that medication by removing a previously covered drug from their formulary (their list of covered drugs), increasing the drug’s copay or barring the use of co-pay coupons that make it affordable, or by moving the drug to a higher-cost tier in their plan.

All of these approaches may reduce short-term costs for the insurer. But they also increase costs to the patient. Sometimes the new cost to a patient is simply more than they can afford, which can result in medication abandonment — and serious health consequences.

Research shows patients subjected to a non-medical switch spend more time visiting their physicians, seeing specialists and undergoing additional tests. They can miss work and may seek emergency care at the hospital or emergency clinic. These are all expensive outcomes which, ironically, can often wipe out the insurance company’s savings from not paying for the doctor-prescribed medication.

In far too many cases, non-medical switching not only jeopardizes a patient’s health, but also ends up being the more-costly option for the insurance company. Institute for Patient Access research found that non-medical switches to lower costs drugs resulted in higher non-drug expenses later on. Patients who remained stable on their medications had the lowest per-month spending.

Non-medical switching is a common – and expensive – problem in Texas. An online survey found that two-thirds of Texas patients with chronic conditions had lost access to a medication their physician had prescribed because of an insurance company formulary change. Among patients who were forced off their original prescription drugs, 90 percent reported that the switch had increased their out-of-pocket costs.

Texas House Bill 2099 would, on a patient-by-patient basis, prohibit insurance companies from switching a patient off a prescribed medication upon plan renewal if the patient has been stable on that drug. It builds upon important patient protections authored by Sen. Kelly Hancock in 2017 and is a commonsense approach to a serious problem that can prove devastating for Texans dealing with serious illness. HB 2099 passed the Texas House of Representatives and has been referred to the Senate Committee on Business & Commerce, where it will be heard on May 14. Please encourage your legislators in Austin to support HB 2099.

Safi Shareef, M.D., is a member of the clinical staff at Texas Child Neurology.
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