As a rheumatologist, I work with patients every day who are suffering from complex, chronic conditions, such as arthritis and rheumatic illness. These diagnoses do not have one-size-fits-all solutions, and effective management often requires many doctor appointments and specialty medicines — expenses that can add up quickly.
In my 17 years of working in medicine, I’ve seen too many patients go without their medications — not because they don’t value their health, but because they’re unable to pay hundreds of dollars at the pharmacy counter on top of their monthly premiums, all while trying to meet their deductibles.
Dr. Timothy Lonesky
For many patients seeking relief from expensive hospital and pharmacy bills, cost-sharing programs have been a true lifeline. Cost-sharing works by allowing patients with chronic conditions to use pharmaceutical coupons toward specialty medications or by allowing a third party to make payments toward a patient’s overall deductible. In both situations, the insurer still gets paid and the individual patient ends up paying much less out-of-pocket.
Thanks to cost-sharing programs, Kentuckians have been able to more easily access the innovative medicines and therapies prescribed by their doctors, keeping them healthier and out of the hospital. Despite these benefits, some health insurers have found a loophole that effectively penalizes patients for using third-party assistance and forces them to pay more.
Here’s how this loophole works. Imagine you’re fresh out of college and renting your first apartment. Your parents have graciously paid your first month’s rent so you can focus on your new job. A few weeks later, you receive an email from your landlord acknowledging the payment from your parents but demanding that you write an additional rent check because your parent’s generosity “doesn’t count” toward your rent.
This same thing is happening in the health insurance industry. And worse, it’s becoming standard practice and hurting some of our most vulnerable and low-income patients.
Last year, the Department of Health and Human Services issued a rule allowing health insurers to continue this harmful practice—something they refer to as “accumulator adjustment programs.” This is a complicated way of saying it’s okay for insurance plans to reject cost-sharing and that they aren’t required to count coupons toward a patient’s deductible or out-of-pocket maximum.
The result is that patients are being double-charged. In the apartment example, the landlord pocketed rent from you and your parents. It’s the same thing when an insurance company accepts a coupon but refuses to apply it to your deductible and out-of-pocket maximum.
Thankfully, a solution to this unfair and deceptive practice is at the Kentucky legislature’s fingertips. Sen. Ralph Alvarado and Rep. Danny Bentley have filed Senate Bill 45 and House Bill 114, respectively, to ban accumulator adjustment programs and require health insurers to count all payments toward a patient’s out-of-pocket maximum and overall deductible, regardless of how they’re made.
Without action from the legislature to pass these bills in 2021, health insurers—who are experiencing record-high profit margins—will continue to pad their bottom lines while the patients they’re meant to serve continue to pay more and more at the pharmacy counter.
For many patients living with rheumatoid arthritis, hemophilia, epilepsy and other chronic conditions, the threat of an expensive pharmacy bill is enough to make them skip doses or even abandon their medications altogether. After one health insurer imposed an accumulator adjustment program for autoimmune medications, refill rates dropped 12 percent in just one year, and the number of patients who stopped the drug entirely increased 400 percent, according to a 2019 AMCP Nexus study.
This is not a road our Commonwealth wants to go down. It’s time to do the right thing and stop double-charging patients for the medications, treatments and therapies they need to live healthy lives. In 2021, that means putting patients over profits and passing legislation to put an end to harmful accumulator adjustment programs once and for all.
Dr. Timothy Lonesky is a rheumatology specialist and has been practicing medicine since 2004. He currently works at Lake Cumberland Rheumatology in Somerset.
