Connecticut Takes Step in the Right Direction to Protect Pain Patients

Connecticut Takes Step in the Right Direction to Protect Pain Patients

Legislation Would Keep Insurers from Increasing Out-of-Pocket Costs, Removing Coverage or Restricting Access to Medicines During the Health Plan Year

By Shaina Smith

Did you know that there are currently no regulations in Connecticut that prohibit health plans from changing contracted pharmacy benefits in the middle of the year, when individuals are locked into their plans? Unfortunately, that is the case in several states across the nation. Luckily, Rep. Michelle L. Cook (D- Torrington) and Rep. Linda A. Orange (D- Colchester) of Connecticut are working to close the loopholes for chronic pain patients.

Shaina Smith

House Bill 6622 was recently filed and would guarantee that individuals receive the prescription drug coverage they signed up for by limiting when insurer policies can change prescription drug formularies during the plan year. Without such a law in place, insurers are able to take advantage of the existing loopholes to save on costs, and, at any time, may increase out-of-pocket costs, enact more restrictions on coverage, or remove coverage of a prescription medication altogether. These reductions to coverage are often done to try to force a patient off of his or her current medication and onto an insurer-preferred drug.

This particular practice is known as “non-medical switching” because patients are forced to switch for financial reasons, as opposed to medical ones. HB 6622 would mitigate this practice by prohibiting insurers from making reductions to their prescription benefit plans for duration of the policy term. U.S. Pain Foundation has and will continue raising awareness in various states this session and in the future to make lawmakers aware of this negative practice. Currently, the organization is in the process of creating a grassroots coalition that would support HB 6622 and possibly other legislation that aims to benefit the chronic pain community. So far, the National Infusion Center Association, Global Healthy Living Foundation, Lupus and Allied Diseases Association and Aimed Alliance have committed to the Connecticut cause.

“Changing a patient’s prescription without prior warning and while they are still locked into their health plan is a dangerous practice. It not only interrupts the treatment recommended by a patient’s physician, but can also lead to higher medical costs in the long run,” Rep. Cook (D-Torrington) said. “This legislation would give patients the peace of mind that they will have access to the medication they need for the duration of their plan.”

The practice of non-medical switching is becoming an increasing problem across the nation for individuals from already vulnerable populations, including people with chronic pain and mental illness. As a resident of Connecticut and person living with an incurable connective tissue disorder, this legislation just makes sense. If consumers, which includes chronic pain patients, cannot change their health plans in the middle of a plan year, insurers should not be able to alter their prescription drug benefits either. Every year during open enrollment, families across the state carefully choose health plans that accommodate their needs and cover the treatments they take to stay stable, healthy and productive. Unforeseen changes to a family’s pharmacy benefits are not only devastating their budgets, but also to their health.

This sentiment is not only shared by U.S. Pain Foundation, but other partner organizations, as well as nationally recognized entities. For example, the consumer advisory group of the National Association of Insurance Commissioners reported mid-year formulary changes can have “significant consequences for consumers”. At the federal level, Medicare placed various limitations on mid-year formulary changes for medications covered under Part D. In fact, Part D sponsors must seek the approval of the Centers for Medicare and Medicaid Services for any negative formulary changes in addition to providing 60 days of advance, written notice of an approved negative change to the affected enrollees.

Typically, clinicians aren’t made aware of the switch until after it happens and are limited in their ability to appeal the change. Meanwhile, patients may experience increased symptoms, side effects and even relapse as they struggle to adjust to the new medication that may not be as effective as the original or might cause an adverse reaction.

In fact, numerous studies show non-medical switching may result in poorer health outcomes, especially for those with chronic conditions, and, as a result, may actually increase overall health care costs. For example, one report published by the Epilepsy Foundation found that patients with epilepsy who were switched off their original medication experienced more breakthrough seizures and sought more inpatient and emergency care than those were not switched. In addition, the journal, Value in Health, published an analysis of patients with rheumatoid arthritis, Crohn’s, psoriasis and other autoimmune conditions who were switched and found they incurred 37 percent higher medical costs than average. Another study, published in Psychiatric Services, found that patients with mental illnesses who were switched off their medication due to coverage changes were three times as likely to be homeless.

“House Bill 6622 fills a dangerous void in consumer protection by recognizing that insurers should provide the health plan benefits their enrollees sign up for,” said Emily Lemiska, associate director of State Advocacy for U.S. Pain Foundation and also a resident of Connecticut. “Without this legislation, Connecticut families will continue to face unexpected costs and restrictions and be unable to get the medications they need.”

While the bill would prohibit insurers from reducing prescription coverage during the plan year, it would not impede insurers from adding medications to their formularies, including new generic products, or making changes necessary for safety reasons outlined by the U.S. Food and Drug Administration. It also would not affect or prohibit generic substitution.

Outside of Connecticut, U.S. Pain Foundation belongs to several coalitions proposing similar legislation in states including Florida (Floridians for Reliable Health Coverage), Colorado, New Jersey and Washington state. We’re also raising awareness on the issue in Tennessee, where we’ve formed the TN Patient Stability Coalition and in Illinois, where we’re co-leading the Fair Care Coalition.

If patient or provider groups are interested in joining the grassroots coalition effort in CT, please feel free to reach out to me directly: shaina@uspainfoundation.org

Authored by: Shaina Smith

There are 10 comments for this article
  1. connie at 1:51 am

    Carla, I am using facts such as Medicare didn’t even cover insulin for my 80 yr old diabetic aunt. I haven’t had the dubious pleasure of dealing with Medicare personally but as a foster parent and adoptive parent of a medically fragile child so dealt with Medicaid for years before changes in coverage limited further what was covered and I certainly wouldn’t want to deal with it now! Heck I wouldn’t want to deal with his medical issues at all in today’s medical environment that puts unreasonable restrictions on needed medication and treatment.

  2. Carla Cheshire at 6:33 pm

    Connie, IMO Medicare is excellent. It has saved my life as no commercial insurance would cover me due to pre-existing conditions. It is the most successful US program for seniors and the disabled and was started because insurance companies didn’t want to cover seniors because they couldn’t make enough money off of them. You pay around $100 a month and it covers 80% of all medical. There are provisions for medical equipment, health screenings and nursing homes. Seniors can buy Supplemental Insurance to cover the other 20% if they want. You do not have to. You can probably opt out totally and pay for private insurance yourself if you wish but it would cost much more.

    Only people who have worked and payed in to SS or are married for over 10 years to a spouse that paid in can get SS. The healthcare that a non-US citizen would get is going to be the ER or County hospitals, if they will take them at all. I believe you are mis-informed about illegal persons getting SS and Medicare.

    The Republicans want to privatize SS and make Medicare a voucher program. I think this would be a huge blunder. What they really want to do is give SS $ to Wall St. I prefer not to gamble my retirement in Wall St’s hands. Vouchers and Health Savings accounts are ideas to let seniors buy Private Insurance. That’s great unless you have health problems as the cost will be at least double for those with illnesses as you go into a risk pool. So be happy you will be getting Medicare. No seniors that I know of are willing to quit the program. Hope this sheds a little light.

  3. connie at 2:29 am

    At 62 I still have a couple of years before I deal with the giant rip-off called Medicare. I am totally confused with the whole thing! As far as I can tell from this vantage point Medicare pretty much doesn’t cover squat yet we are required to purchase it and a supplemental insurance. I always thought Medicare and social security were paid for with our taxes during our working years. Guess I was totally wrong on that one! I am still trying to figure out what our taxes actually pay for other than a check and free medical for people who never paid taxes and aren’t even citizens! Something is terribly wrong with this picture!

  4. Jean Price at 8:47 am

    (David…don’t know if my comment might help clarify it…the article addresses the same issues we have with any Medicare Part D plan coverage, as far as the unfairness and how that works.)

    Medicare has always messed with our pocketbooks and our well being by this kind of problem regarding our needed medication, through the Part D plans! We are required to pick a plan/insurance provider by the first part of December each year…or remain with the one we have. HOWEVER, the provider can THEN change their formulary AFTER January first, resulting in some or many of our medications being denied! An appeal then has to be submitted and it’s anyone’s guess if it will be approved! This also depends on your doctors timely response and you might find yourself without medication until it’s resolved. (Most do allow a one month graced supply, and they send a letter stating it’s not covered further. Yet if you miss that letter, or overlook it, you’ll have problems getting any refills and have to start the process then, already behind the eight ball!

    So why even bother to find a plan each year which fits your needs?! Last year, before January was up, I received four letters on four different medications that were denied coverage…NO LONGER on formulary, even though I had expressly chosen a plan to include all my medication needs! AND PAID MORE FOR IT. And worse, there was nothing I could do…we are locked in for a whole year! I again changed companies this year…same thing, already I’ve had three medications denied, deemed not on formulary…and I paid triple for this policy because they covered some meds that had been denied previously!! From the frying pan in to the fire! No recourse at all! Just the breaks of how it’s ended up!

    It’s well known our physicians hate January and February most with all the appeals they have to write! I had one doctor say he didn’t go to medical school just to write out these ridiculous appeals, multiple times a year for most of his patients! And I can’t blame him…these appeals are really a favor to us, it’s our insurance company, andmour need! Sadly, this all detracts from the time and the care he can give patients! And it takes an additional staff person to cover all the added paper work and phone calls…or an overloaded staff who has to assume this role now too! Many doctors would rather switch or even discontinue a medication instead, although it had helped the patient and had produced no intolerable side effects! How can this be fair? Or be good medical practice?

    This all means an insurance company can conceivably see what medications are most ordered by its clients, and then take those OFF formulary, DENYING COVERAGE! Saving them lots of money, especially when you think of the numbers of people affected! Always seems to be the money! Yes, follow the money…once again! Nothing to keep them from it, the way it’s set up now! Hopefully what that state is doing will catch on for more states and our government as far as Part D plans! Until then, we are just out of luck,, plus out of medicines or out of money…or both!

    For us then, with the current practice….we are talking major added expenditures….if we stay on the previous meds and just pay outright! Yet there’s also another big expense possible if we have to change medications, even when we run them through insurance, they can cost much more!! Additionally, generics are no longer to be considered less expensive across the board! And this just seems crazy…yet again, involves profit!! If your insurance company has a contract with the pharmaceutical brand name maker, the brand name medication can end up being a little more or less expensive than the generic. HOWEVER, it can also be much more expensive, AND the generic, ALTHOUGH MUCH LESS, isn’t on formulary….so to buy it yourself at a cash price is more expensive overall!! And your hand are tied! You might get an appeal okayed for the generic, yet it will be at a higher tier, and likely not be a savings! The proverbial rock and a hard place!!

    You would think there would be an option to at least change insurance providers…but no! Not until a full year at the regular sign up time. For this and many other reasons, Medicare part D is a poor plan, boardering on just plain criminal! Probably the only real advantage it had was lowering unemployment!! Since it takes detailed training and a whole army of people to navigate the complicated system! They must spend zillions of hours on the phone, trying to clarify coverage and inform people of the sad answers about benefits…with benefits that insanely change for the WORSE AFTER you’ve already laid out thousands of dollars a year! The infamous DOUGHNUT HOLE!! Or coverage gap, built in LACK OF ALL COVERAGE, until the next stage is reached! (The only possible savings here is IF the insurance company has come kind of discount contract with either the pharmaceutical company or the pharmacy. An example of this would be a $790 medication might ONLY cost $620 for the month! Still prohibitive for most of us! Additionally, in general prices can vary from one pharmacy retailer to another, based on their company’s own volume of sales for a particular medicine! Yet I’ve found this is hard to track down and keep up with). In general, even in the coverage phases, prices vary among what’s called “preferred” and “network” pharmacies, over other ohsrmacies not on either list. This varies with insurance companies, each having their own choices and contracts.

    Rarely does anyone make it out of the coverage gap! That takes an additional out of pocket of more thousands!! And if it does happen, it’s usually in the last month of the coverage year, and for those with over approximately $5000 out of pocket expenses already…although that cap amount keeps going up! It is at times hard to realize why we even pay for these plans! They range anywhere from $20 to $150++ a year, in addition to the Medicare premiums, and add in a supplemental plan, if you can swing it!! Those can be a wide range of costs…depending on the type of plan. With Medicare for those over 65, a decent supplement (like a plan F) would run around $180-$225 month.

    If you’re on Medicare (like from a disability) and not 65, those supplement plans could cost over $700 a month!! (For those people, one of the Medicare Advantage plans would likely be a lot better, cost wise, and no supplement is allowed, or really needed.) If you are a person who has multiple conditions, aside from scraping by and trying to pay the premiums, bankruptcy or the lottery is about the only other viable option to pay for health!! Sad! I would say it’s time our government take over everything…and things would be better. Yet you only have to look at the VA system to realize that’s not the best answer…for years our military has received less than acceptable care! Or NO care! So unless our lawmakers and president themselves are made to ALSO abide by the plans they set up for us citizens, we are NOT likely TO EVER HAVE a fair and reasonable, affordable, quality health care plan nor good coverage for our worthy veterans! Isn’t this all a national shame!? I think it is! A big one!

    Few over 70 could figure Part D out…without a lot of help when it first appeared! Not much easier now! I’m so happy I don’t have a child in government who voted for this plan…I would seriously have to disown them! I’d be miserably disappointed in their poor values and lack of compassion! It’s ridiculous, and these yearly changes make it impossible to pick a plan that’s actually good for you…and have it remain so! In general, what good is this kind of set up for the individual? With all the convoluted mess of little and big restrictions and the many variations and added expenses!! I suppose it’s anyone’s guess…but it’s obviously making insurance companies money, and that drives the country, doesn’t it?! Ugh!

  5. David at 5:39 am

    Can someone explain this better to me I can read something and sometimes dont under stand I have chronic pain and just got out of the hospital again had another surgery a bowel resection it is crazy I dont know why they didnt due it in 2012 I have been in and out of the hospital and about a month ago I got my pain meds and couldnt get one of them because i wasnt or didnt have cancer So the insurance companies cant deny me??? Anymore if it passes.I am happy that ct is maybe getting it about people with chronic pain and other health issues. Thank you

  6. connie at 12:03 pm

    Too little too late. It’s not likely that any laws that get passed are going to actually help the chronic pain patients get effective and needed medical care because that’s not where the money is!

  7. Veronica at 9:19 am

    I live in northern Wisconsin, and just received a phone call from my doctor. They will no longer be prescribing any pain meds permanently. Was I left with an option? No. Do they care that this is lifelong pain, from numerous health issues, that can’t be fixed? No. I’m at the bottom of the barrel, with no way out….

  8. Suzanne Stewart at 8:13 am

    Hi Shaina! Please let me know if I need to do something, write someone or go to Lansing to help this cause if it occurs in Michigan

  9. Carla Cheshire at 7:52 am

    All we want is quality, affordable health care that covers everyone in this country. I believe a single-payer system is the only way.

    Day after day it’s proven that Big Insurance, Big Pharma and Big Hospital Groups are out for the largest profits they can get using whatever loopholes and trickery they can to gouge the consumer. I’ve had insurance companies drop my coverage. You say”Oh, they can’t do that!” Here’s how. They changed the name of the company, kept the same address and phone and dumped all their policy holders.

    We will never have affordable care when these companies are traded on the stock market and must have high returns. The law says they have a fiduciary responsibility to do so! Hence, bills you can’t figure out, phantom charges and you cannot cost compare a procedure as they say they don’t know what it costs.

    Appalling way to do business, to take advantage of the sick, to profit off of one’s illness. Then to stick it to them when their fighting for their lives is repugnant IMO.

  10. Bob Schubring at 5:38 am

    The headline is excessively optimistic and misleading. Connecticut won’t actually take this step, unless a majority of the other Connecticut legislators vote to take it. Meanwhile, insurers are spending gobs of money promoting the pernicious notion, that chronic pain is purely psychological and that doctors who treat intractable pain with pain medicines, are mentally unbalanced somehow. Those corporations have already co-opted Senator Schumer and Senator Manchin to their viewpoint. Schumer and Manchin, together with candidate Hillary Clinton, proposed to punish us out of noticing pain by putting a tax on the medicines we take. Merely proposing some legislation in one state, that might modify insurer behavior slightly, if it passes, simply isn’t solving the problem. Insurers will get federal legislation passed, if their lobbyists can buy it.

    The only permanent way to reform this problem, is to make Congressmen and Senators legally liable to lawsuits for damages, when they act against the public interest. Right now, they are impossible to sue. Lobbyists know this and teach this to their clients. An insurer who harms a patient can be sued. An insurer who goes along with a law, cannot be sued. So the insurer pays the lobbyist to motivate Congressmen and Senators to create the law the insurer wants. The tactic is so fiendishly effective, that top executives in US corporations are grossly overpaid, compared to their Japanese or European counterparts. It is illegal for a corporation to give money to elect a politician. But it is perfectly legal for a corporation to overpay it’s executives, so that those executives can write a big fat personal check once a month, to each of their favorite politicians. The politician creates the law. The corporation does wrongful things that it paid to have made legal. As long as the politician is immune from suit, corporations will continue to buy laws that benefit them.