The stories described a series of patients losing control of their own health care: A son coping with ADHD thanks to medication whose insurance suddenly wouldn’t cover the pills. A pharmacist unilaterally substituting a different blood pressure medication because of an insurer’s directive. Epilepsy medication switched without warning, leading to a recurrence of symptoms after years without an episode.
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And the most harrowing tale of the bunch was a description of an elderly woman managing emphysema who was hospitalized for 10 days because her inhaler medication was changed without her having any say.
These vignettes from health care advocacy groups were relayed to the Pennsylvania House Consumer Affairs Committee to garner support for House Bill 2113, which would forbid insurers from making unilateral mid-year changes to patients’ drug regimens. The bill author’s rationale is that while patients are locked into an annual contract with their insurer, the insurance company is not similarly bound to honor expectations set at the onset of the annual contract period.
“Most Pennsylvanians are surprised to find that their health plan can change its benefits at any time during the policy year, even though the consumer may have carefully researched their plan to ensure that it met the family’s health and financial needs, and even though consumers are locked into the policy until the next open enrollment period,” Rep. Donna Oberlander, R-Clarion, told the committee while presenting her bill. “This unfair scenario is especially true for those living with chronic health conditions such as epilepsy, diabetes or hemophilia, in addition to mental health diagnoses and those who rely on continuous and consistent treatment plans to manage their health.”
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Oberlander’s bill carves out some scenarios where insurers would still be able to make changes. Generic substitutions would be allowed, and the insurance companies would be free to make changes to the formulary for any medication not currently being used by a patient. Also, any drug or treatment found to be unsafe by the federal Food and Drug Administration could be changed.
After the panel of health care advocates shared their anecdotal examples of individuals who had been affected by mid-year changes to their prescriptions, Rep. Warren Kampf, R-Paoli, tried to get an idea of how widespread the problem is, asking the advocates how often it occurs in the state.
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“We have many members of our coalition who have these kinds of stories and experiences, so it’s a widespread across our state,” said Suzanna Masartis, the executive director of the Community Liver Alliance, which in turn is a member of the Pennsylvanians for Fair Health Coverage coalition. “I don’t know how to quantify it with numbers. I can’t say there’s 25 or 250, but it’s many, much, often.”
The Pennsylvanians for Fair Health Coverage group is an association of 14 entities such as the Pennsylvania Medical Society and the Pennsylvania Society of Physician Assistants to lobby for legislation such as HB2113.
A panel of representatives from the insurance industry expressed bafflement that the topic was even under discussion, expressing repeatedly that they don’t hear from their customers that mid-year changes are an issue.
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“We’re very interested to kind of hear what what we just heard from the patients prior to this because … we don’t receive a ton of complaints,” said Arielle Phillips, government affairs director for Independence Blue Cross. “We don’t have a widespread pattern of complaints here, so this was something that was a little bit new to us when we heard about the issue.”
Sam Marshall, president and CEO of the Insurance Federation of Pennsylvania, argued that making changes during the year was about making experiences better for their customers, not worse.
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“Drugs evolve, and therefore our coverage of them evolves in real time,” he said. “It’s not a calendar year basis. You learn about good effects, bad effects, other alternatives, other means of coverage during the course of a year. Your coverage of those drugs should evolve with that.”
Doug Furness, senior director of government and regulatory affairs of Capital BlueCross, talked about the recourse that policyholders have when they’re not happy with a prescription change.
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“In 2017, Capital BlueCross filled 4.8 million prescriptions for our policyholders,” he said. “We received 1,585 complaints out of 4.8 million prescriptions. Of those … complaints, 946 were overturned on behalf of the policyholder. Now I’m going to echo [Phillips], we just don’t see this as a problem.”
Rep. Carl Metzgar, R-Somerset, asked the insurance representatives if there was a way to adjust the bill to make it palatable for their industry.
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“Our constituents can’t get out of the contract,” he said. “They’re in it, they’re stuck to you, they’re married. And you [talk] about an appeal process, but in the meantime the patient’s holding the bag because they’re not getting the treatment. So my question is, can’t we get ourselves to a spot where, unless this medicine is unsafe, they keep getting it during this contract period? Isn’t that fair?”
“I understand where you’re coming from and it makes sense, but in some cases it does go beyond just the safety,’ replied Mike Yantis, vice president of state government affairs for Highmark. “It speaks to the clinical effectiveness and the value proposition of the treatment for the patient.”
Oberlander’s bill currently has 20 co-sponsors in the House and is awaiting further action from the Consumer Affairs Committee.
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