Contributor: Paula Wade
Topic: Pharmacy Cost Control
The health plan industry has become enormously creative in thinking of new ways to shape member and provider behavior to save health costs.
Some of these methods are artful—such as UnitedHealthcare’s development of a plan design specifically for diabetics, a benefit design that is tailored to promote better outcomes and lower cost to members who comply with their care regimen.
But others seem more like blunt instruments designed to keep the sick from accessing needed care, perhaps in hopes of driving off those with health risks. They’re the kind of plan designs that provide the illusion of access, and that a well-designed insurance exchange will have to be careful to flag.
One such “cost-sharing” approach, employed in some of WellPoint’s group PPO products, adds a separate deductible ($250 or $500 per family member) for the pharmacy benefit, above and beyond the plan’s deductible for medical services, and beyond traditional pharmacy copays or even coinsurance. Such a design, particularly in this economy, seems both ham-fisted and wrong-headed: it will discourage members from filling needed prescriptions, regardless of their value in keeping the member healthy.
Another WellPoint design, in the individual market, advertises a four-tier formulary but requires payment of a $7,500 deductible (!) before the benefit covers a drug on Tiers 2, 3 or 4.
Now perhaps this is just a bald attempt to create a plan design sure to repel people with chronic illness – folks who know they need medications in order to live their lives well – in order to avoid risk. Perhaps this is the kind of plan design, particularly in the individual market, that can be priced cheaply and can lurk in under-regulated “market-style” state health exchanges.
As states gear up to write the rules that will apply to their health insurance exchanges this year, these are the kinds of plan design trap-doors that the transparency movement , consumers and Pharma need to watch out for.