Post Scripts: Drug costs – a growing problem for all

It doesn’t take a health expert, or a health care policy holder, to recognize that something is terrible wrong when patients have to pay thousands (yes) a month for drugs that they require to maintain and sustain their health – and hopefully, possibly save their lives. Our sleepy Congress needs to determine why this is happening and what can be done about it

The plight and experience of patients who have recently been hit with sizeable increases in their insurance co-payments for high-price prescription drugs was laid out in a recent story in The New York Times. Instead of paying a modest $10 to $33 co-payment, as is usually the case for cheaper drugs, patients who require especially costly medications are being forced to pay 20 to 30 percent of the bill (up to an annual maximum) for drugs that can cost patients tens of thousands of dollars (or even more) a year in some extreme instances.

Such drugs – what insurers call Tier 4 medicines – are used to treat such serious illnesses as multiple sclerosis, hemophilia, certain cancers and rheumatoid arthritis. Since there are usually no cheaper alternatives, patients must pay or do without, unless they can obtain their needed medicines through some charitable plan.

There is little doubt that the so-called tiered "formularies" in which co-payments rise along with the cost of the drugs, are a reasonable and sensible approach for encouraging consumers to use the cheapest drug suitable, or possible, for their condition. The system seems to break down, however, when it moves into Tier 4 drugs where co-payments can be huge, and possible alternatives simply don’t exist.

Insurers say that forcing patients to pay more for unusually high-priced medications allows them to keep down the premiums charged to everybody else. That turns the ordinary notion of insurance topsy-turvy. Instead of spreading the costs and risks across a wide pool of very sick patients from financial ruin, insurers are gouging the most seriously ill patients to keep the premiums down for healthier people.

Today’s health system is so complex that it is hard to place the blame for this injustice. The major drug companies, in particular the biotechnology companies, are at the bottom of the problem. They quite often charge huge prices for monopoly drugs that were developed with heavy government assistance. Washington needs to rein them in by encouraging generic competition for biological drugs and allowing government programs to negotiate lower prices.

Employers, including the federal government, also bear responsibility. They have been pressing to reduce their prescription drug expenses as well as all health care expenditures by shifting more of the burden to patients. What’s new about that?

One patient who had been paying only $20 a month for a month’s supply of a multiple sclerosis drug was truly shocked when the charges reached $325 a month. (It has since been suspended.) Another patient found that his co-payment for a newly discovered leukemia drug would exceed $4,000 for a 90-day supply, so he deferred purchasing it.

Sadly, if patients do without needed medications or put off taking them, the likely result will be sicker patients, and high costs down the road. That’s not a pleasant development for most of us.

What is not clear as of now is whether or not insurers are primarily reacting to pressure from employers, or else exploiting the situation to increase their profits. Our sleepy Congress needs to probe the situation more closely and find out just how many patients are facing enormous drug and surgical bills and how best to protect the public from medical and financial disaster.

This is a growing problem for all of us and it will not go away without serious confrontation.