Consumers Support Laws to Limit Payer Prescription Switching

December 19, 2017 - The vast majority of patients living with chronic diseases would support legislation to limit a payer’s ability to switch their prescriptions without medical necessity, according to a new series of surveys.  

Ninety-four percent of Massachusetts patients with chronic diseases, 94 percent of Florida patients with chronic diseases, and 98 percent of Tennessee patients with chronic diseases support legislation that would limit a payer’s ability to make drug formulary adjustments that would force a beneficiary to change their prescriptions in order to financially benefit payers.

Currently, payers can make formulary changes during a health plan year that remove a drug from a beneficiary's health plan, increase a patient’s out-of-pocket costs, and change the tier of a drug.

These changes to prescription drug benefits can result in significant health and finance-related implications for beneficiaries when preferred drug treatments are no longer available, stated Seth Ginsberg, president and co-founder of the Global Health Living Foundation and a member of the Massachusetts Patient Access and Safety Coalition.

“The contract that Massachusetts residents will sign [when enrolling in a federal health insurance marketplace plan] is very specific, but what they may not realize is that their insurer is allowed to alter the contract by reducing their drug coverage at any time during the plan year,” Ginsberg said.

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“Not only is the contract unfair to consumers, but it puts patients’ health at risk when access to their medication becomes uncertain. It’s time for legislators to protect patients from non-medical switching.”

Surveyed patients from each state experienced similar levels of financial burden when their payers made changes that affected the price of their medications. Patients often believe that payers coerce consumers into finance-related prescription changes.

In Massachusetts, 66 percent of patients were unable to afford out-of-pocket costs for medications and were forced to switch to a lower cost alternative because of formulary changes. Another 68 percent of patients said payers in the state coerced them into a non-medical prescription change.

The financial outcomes of prescription-switching in Florida caused chronic disease patients to experience concerns with out-of-pocket spending. Ninety-four percent of patients said a medication’s out-of-pocket cost was a major factor in determining whether or not to purchase a prescription.

Additionally, 52 percent of Florida patients said that a payer financially coerced them to change a prescription.

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Sixty-seven percent of chronic disease patients in Tennessee were unable to to afford out-of-pocket spending increases for their new medication. Forty percent also reported being financially coerced by payers to change a prescription.

Non-medical prescription switching contributed to negative side effects after patients were forced to use less effective alternative drugs, the participants said.

Seventy percent Massachusetts of patients found their new drug was anywhere from slightly less effective to significantly less effective. Another 61 percent switched to a medication and experienced a side effect.

Side-effects from non-medically switched medications worsened overtime and contributed to significant health detriments among Massachusetts patients.

Eighty-six percent of Massachusetts patients said their new drug side effects were worse than any side effects from their preferred medications. Forty-six percent of patients reported seeing a provider or experiencing an ED admission from non-medically switched prescription side effects.

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In Florida, 61 percent of patients that switched prescriptions had to try multiple medications before finding one that worked. Seventy-seven percent of patients switched to a new medication and experienced a side effect. Ninety-two percent of those patients said their side effects did not improve.

Sixty-seven percent of Florida patients experienced worse side-effects after switching from their previous medications. Fifty-eight percent of patients experienced an adverse side effect from a new non-medically switched medication, 36 percent were hospitalized from side effects, and 41 percent reported missing work because of new drug side effects.

Tennessee patients that changed prescriptions also reported high rates of ineffective treatment and negative side effects.

Eighty-nine percent of Tennessee patients said their new drug was anywhere from slightly less effectively to significantly less effective than their old drug. Fifty-eight of patients also experienced a side effect with their new medications and 95 percent of these patients said new side effects were worse than previous ones.

Thirty-two percent of Tennessee patients reported missing work because of debilitating new drug side effects.

The data in each state revealed that payers did not always inform or update patients about formulary changes.

In Massachusetts, 42 percent of patients did not receive information or updates about formulary changes and only 24 percent of payers sent out communications to beneficiaries about major formulary changes.

Forty-eight percent of patients in Florida did not receive information formulary updates and 31 percent of payers did not inform beneficiaries about significant formulary changes.

Similar results were reported by patients in Tennessee. Forty-four percent of respondents did not receive formulary updates and 48 percent of payers sent out communications about major changes in formulary.

Payers should to consider the possible safety implications of adjusting drug formulary and communicate about the possible financial and health implications of non-medical prescription switching.