There has been some movement in the state's legislature to address things like copay accumulators,
open formularies, and pharmacy access.
We're joined by someone on the front lines of this work, Rob Gumbert, I'm sorry, let's
start over.
There has been some movement in the state's legislature to address things like copay accumulators,
open formularies, and pharmacy access.
We're joined by someone on the front lines of this work.
Rob Gunderman, president and CEO of the Coalition of Wisconsin Aging and Health Groups, and
thanks for being here.
Thanks for having me.
So tell me a little bit about how you got started in all of this.
Sure.
Well, I started getting calls from patients who were trying to get their medications.
They'd go to the pharmacy counter, and they were being told that it would be thousands
of dollars to get a medication that they're used to paying $30, $40, $50, whatever their
copay was.
And they were learning that a copay accumulator had been applied to their policy, and this
is a new thing insurance companies are doing, where if you have an expensive medication,
if you have multiple sclerosis or any of these conditions that have expensive medications,
manufacturers will frequently provide you with copay assistance.
So what they do is they give you a card, and when you go to the pharmacy counter, you
present that card, and the manufacturer is actually paying for your medication until
you get to the point where your donut hole has been, your deductible has been filled,
and then at that point you're just paying the copay.
Insurers have started taking the money that is being paid by the pharmaceutical manufacturer,
but not applying it to the patient's deductible and not telling the patient.
So the patient goes up, they think they're going to pay their copay, and it's $3, $4, $5,000.
And the one that really struck me was a woman with a heart condition who needed this heart
medication to live, and she went up like she always does to buy her medication, they said
it was going to be $3,800.
They didn't have $3,800, and her husband had to go to the bank and take out a loan so
she could get the medication she needs to live, and I realized we have a problem here, and
that woman who I've come to know, her family is going into debt more and more every year
having to deal with this, so that's how I got involved in this.
And as you've been working on these issues, is this just all too common?
You know, when I started out in this, it wasn't that common.
I was seeing in a plan here and people were starting to come to me, now it's become very
common.
It's spreading like wildfire.
There are very few plans left.
I don't even know of a plan left in Wisconsin that doesn't have a copay accumulator other
than the group, the state insurance plan.
And since then, what is the impact you've seen on patients?
What does this do to someone who's making this impossible decision?
Well, a couple of things.
One, the financial stress that it's putting families under that just can't afford this,
right?
The other piece is, I've had people tell me they're not going to take their medication
anymore.
I had a friend of mine who has MS, and he says, if they put one of these copay accumulators
on my policy, I'm going to stop taking my medication.
So, you know, you then end up with more problems with their health, and I don't think that's
a cost-saving measure by, you know, taking this money, they may get some money out of
it.
But I think in the long run, the increased health expenses that you're going to have for people
if they stop taking their medications are going to offset that.
And as you've said, and as we've seen in these stories, people don't know until they're
so far along that they owe all this extra money.
There's no ability to have a payment plan for your medications, so you either get it or
you don't.
How difficult is it for people to even know that something like this is on their plan?
How much of it is just poor communication?
That's a lot of it.
It's very difficult.
I look at some of these plans, 50, 60 pages, and who's going to read 50, 60 pages of fine
print?
Some of this is a very small, it's hard to read, especially if your eyes are so good
as mine aren't anymore.
It's hard to spot this little clause in there that says, and even if you read it, if you
don't know already what a copay accumulator is, you're not going to understand what they're
saying in there.
And there's accumulators, maximizers, and those sound like good things.
They do.
They use catchy terminology, and they've probably run this through marketing groups to see what
people like and what people don't like.
But you're exactly right, they're copay accumulators, they're copay maximizers, they're all doing
essentially the same thing, but just from a little bit different angle.
Now, Senate President Mary Felskowski has been working on legislation like this for many
years, many sessions.
What are the concerns that state lawmakers have had making it so difficult to move this
forward?
Sure.
I think the one thing that's really held us up with state law, and a couple of arguments
that the insurers have made.
One is that this will drive patients to more expensive brand name medications.
We know 98 percent of the medications in this group, these expensive medications, there
isn't a generic four.
But Senator Felskowski put a language in the bill saying that this only applies to medications
for which there's not a generic equivalent, so that's off the table.
They're still making that argument though.
The other argument that we're hearing is that it will drive up insurance premiums, but there
are studies that have been done looking at states that have already passed this type
of legislation where the premiums haven't increased, and conversely studies have looked
at states that haven't passed this legislation, and premiums aren't lower there, like in Wisconsin
our premiums aren't lower where we don't have that.
And the current legislation for this session is still in play.
Where does it currently stand and what, if anything, has changed throughout this session
as it's gone through committee?
Sure.
Well, we had a committee hearing, which was the first, this is the second session that
we've tried to run this bill, and we weren't able to get a vote out of committee last session.
This session, we've got a five to zero vote, so the entire committee voted in favor of
passing this out in the Senate, and we expect that to come up to the floor at some point.
In January, we just don't know when, and so there's a definite shift here where the momentum
has shifted.
I think there are 40 co-sponsors on the bill, but I think the votes are there to pass the
bill if we can get the votes.
Overall premiums are going up if people feel like they're not properly covered under a
plan that they're paying a lot of money for every month.
Do you think patients will just end up for going a health plan altogether?
That's our concern, our worry.
I think there are people who, they're going to look at this and say, I'm paying so much
out of pocket anyway, I'm not ever using the insurance.
So what's the point of having it?
And then when they have something serious happen, then it's more problems, and it's not like
someone isn't paying for that.
We saw in Colchmann next story that he didn't know that the formulary had changed, and that's
something that's been a point of contention in the legislation.
Has that changed as it's gone through committee?
Yeah, so the insurer is wanting to be able to change the formulary throughout the year,
and right now they can only change it during the window when people can change plans.
And so we don't have a problem with that as long as they weren't able to force the patient
to change their medication mid-year.
So I think it's actually a benefit to patients because if you're going to make a formulary
change, tell them in June or July, give them as much time as possible to figure out
what they're going to do and find a new plan that will cover whatever the medication is
that they're taking that is going to be leaving your formulary.
So I think I don't see an outside of that.
Now we just saw Congress go through the longest government shutdown in history over these
enhanced tax credits, and we're still seeing premiums go up all around.
How much of this is kind of reaching a turning point as healthcare premiums costs are all
going up and there doesn't seem to be an end in sight?
We're getting to the point where something has to happen.
We can't.
My insurance went up about almost 25% this year.
We can't have 25% annual increases in our health costs, just as Americans we can't afford
it.
So we're going to have to figure something out, and I don't know what that answer is.
I mean people, smarter people than me have been trying to figure this out for a very
long time, but we're going to the point where we have to.
This isn't an option anymore.
We can't afford to keep going the way that we're going.
And for a lot of families without the Affordable Care Act plans being available to them, I
think we're going to have a lot of people who are just not going to be insured.
Anything else you'd like to add?
I think the only thing that I would say is that when you look at this copiate accumulator
piece, it just to me this is just so unfair, and it's been difficult for me to understand
how this has been allowed.
If you and I went out to dinner, and I paid for your dinner, and the restaurant said,
we've adopted a copate policy where you have to pay for your meal, and you say, well,
Rob already paid for my meal.
Yes, and we appreciate that, and we're going to keep his money, but you also have to pay
for your meal.
You would say, if this isn't fair, you're getting paid twice for the meal.
This is what the insurance companies are doing, and they think it's fine.
Well, thank you very much for joining us.
As we've seen, most patients don't get the option of a payment plan for these costly
prescriptions.
You either pay up front or you don't receive treatment.
In all of these stories, complex diagnoses, convoluted health plans, decreasing access
and steep prices are overwhelming patients with impossible decisions, but they're not
always alone.
Patient advocates are stepping in, using their knowledge of the system, and doing what they
can to make sure patients are getting the treatment they need.