The subject of high-cost drug accessibility is in the spotlight following two recent lawsuits brought against Anthem for allegedly withholding hepatitis C treatments. On top of that, California's insurance exchange has added fuel to the fire by becoming the first to implement caps for monthly prescription costs, and the state legislature is considering a bill to do the same for employer-based plans.
Given the scrutiny on the subject, the question now is whether health insurance providers are likely to be pressed into covering high-cost drugs via legal action, legislative action or any other form of public pressure.
Who picks up the bill?
If so, someone still has to pay, notes Nicole Kasabian Evans of the California Association of Health Plans. Insurers would likely have to pass the additional costs along to their general population of consumers via higher premiums, which would in turn impact plan affordability.
Evans suggests the underlying issue that must be addressed to truly make prescription drug coverage affordable is that of the prices being set by pharmaceutical companies.
"We were encouraged by the Covered California board's concerns with skyrocketing drug prices because as more and more drug treatments cost exceed the $100,000 mark we put the affordability of health coverage in jeopardy," Evans told Healthcare Dive.
In the meantime, however, drug companies are defending their prices and it's a wild west for insurers seeking to rein in costs.
Anthem has not publicly commented on the lawsuits, but told the Wall Street Journal that limited clinical data is an issue when it comes to approving hepatitis C treatments. A spokesman noted that the newest Hepatitis C drugs have been approved through the FDA breakthrough therapy process, and have therefore been tested among fewer people than in typical clinical trials, leaving knowledge more limited for these new drugs.
"Given the concerns and relative benefits and harms [of the drugs], our benefits support coverage for members with more advanced stages of liver disease and those at highest risk for liver complications," Anthem said. "Broader use of these drugs and knowledge about the long term effects and potential harms and outcome of various alternative therapies are needed on those with limited effects of infection."
More lawsuits on the horizon?
Some suggest that additional lawsuits against health insurers are likely. "It's every man for themselves and insurance carriers will do whatever they can do to minimize their cost of doing business, including coverage provision interpretation," Randy Vogenberg of Access Market Intelligence, a consulting firm that specializes in managed care, told the Journal.
Pressure should only mount given the skyrocketing levels of annual medication costs in the U.S. According to a newly released analysis by Express Scripts, an estimated 576,000 Americans spent more than the median household income on prescription medications in 2014.
The report found that this group of patients increased by a startling 63% since 2013. During that time, those patients with costs of $100,000 or more nearly tripled to 140,000 people. "The total cost impact to payers from both patient populations is an unsustainable $52 billion a year," the report concludes.
Among the highest cost drivers were compounded therapies, hepatitis C and cancer medications, which comprised almost two-thirds of drug expenses for those patients costing upwards of $100,000 in 2014. The number of patients getting treatment for hepatitis C leaped 733% in 2014.