Download How can we get medications for the under

How Can We Get Medications
for the Underinsured and How
Should We Deal with Denials
From Insurance Companies?
Mark T. Osterman, MD MSCE
Assistant Professor of Medicine
University of Pennsylvania
Disclosures
• Advisory board for Janssen, Abbvie, UCB
• Research grant support from UCB
Outline
• Definitions / statistics
– Uninsured, underinsured, cost sharing
• Affordable Care Act
• Medicare / Medicaid
• Special considerations
– Age 26, end of year, insurance / job loss
• Non-government patient assistance
– CCFA, letters / data, hospitals, pharma,
charitable organizations, clinical trials
• Persistence
Thanks to My Friends
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Peter Higgins
Corey Siegel
Jim Lewis
Laura Wingate
Dorothy Williams & Michelle Grainger
Definitions
• Uninsured: no insurance of any kind
• Underinsured: insured all year but not
enough, or more specifically
– Medical expenses > 10% of annual income
– Annual income < 200% of federal poverty line
and medical expenses > 5% of annual income
– Deductibles > 5% of annual income
• Cost sharing: payment of health care by
both patient and insurance company
Schoen C et al, Health Aff 2005
Cost Sharing
• Deductible
– Amount you pay before insurance starts to pay
– Still have to pay the copay
• Coinsurance
– Your share of costs of health care services (%)
– You pay this after deductible met
• Copay
– Fixed amount you pay for a health care service
– Varies with type of service
Statistics
• In 2012, 32 million < 65 underinsured
– 47 million uninsured, so total 79 million
• By state
– Uninsured (2012)
• <10%: MA, HI, MN, DE, VT, DC, CT, NY, RI, IA, ND, WI
• >15%: TX, NV, FL, AZ, WY, NM, NC, GA, AL, AK
– Uninsured + underinsured (2012):
• Low: MA – 14%
• High: ID, FL, NV, NM, TX – 36-38%
www.commonwealthfund.org
Henry J. Kaiser Family Foundation
Why the Lack of Insurance
• Limited income
• Demographics
– Hispanic, remote rural, low education, religion
• Unemployment / underemployment
• Employers do not provide health benefits
• High premium / deductible / coinsurance
– Cost sharing: move burden to patient
• Restricted benefits
• Youth: feel invincible, limited income
www.Medicare.gov
Affordable Care Act
• Enroll 10/1/13 – 3/31/14, 11/15/14 – 2/15/15
– Special enrollment period if miss deadline
• Require most to have health insurance
– Tax penalty unless exempt (>8% of income, no
filing, hardship, short gap, religion, Indian, jail)
• Employers
– Require larger business (> 200 employees) to
offer coverage to all
– Tax credit to small business (< 25 employees)
– Exchanges through which smaller business
(< 100 employees) can purchase coverage
www.hhs.gov
Special Enrollment Period
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Signed up but unable to complete enrollment
Marriage
Having, adopting, or placement of child
Permanent move to new area with different
health plan options
Losing other health coverage
Change in eligibility for premium credits / costsharing subsidies
Newly gaining legal US resident status
Government error during enrollment process
Health plan violates contract
www.hhs.gov
Affordable Care Act
• Expand Medicaid to all non-Medicare-eligible
<65 with income < 133% of fed poverty level
– States 100% fed funded 2014-16, 90% by 2020
• Extend funding for CHIP
• State-based American Health Benefit Exchanges
through which people can buy coverage
• Premium credits and cost-sharing subsidies
with income 100-400% of fed poverty level
• No pre-existing condition exclusions except for
grandfathered plans (purchased before 3/23/10)
• No lifetime limit on coverage for most benefits
www.hhs.gov
Affordable Care Act
• ↓ in uninsured by 10 million in 2014
• May not be as dramatic next year (“lowhanging fruit” captured in 2014)
• Those without insurance the longest may
be most difficult to get signed up
• Other obstacles
– Residence in remote areas
– Lack of internet access
– Less education
– Not up to date with news
Young J, Huffington Post 2014
Affordable Care Act Plans
Plan
Coverage / Costs
Catastrophic <30 who cannot afford other coverage
Must qualify for hardship exemption
Bronze
Silver
Gold
Platinum
Covers ~60%
Lowest premium, highest out-of-pocket costs
Covers ~70%
Lower premium, higher out-of-pocket costs
Premium credits / cost-sharing subsidies
Covers ~80%
Higher premium, lower out-of-pocket costs
Cover ~90%
Highest premium, lowest out-of-pocket costs
Not offered by all insurers
www.hhs.gov
Hardship Exemptions
• Homeless
• Bankruptcy
• Insurance cancelled
and other plans not
affordable
• Ineligible for Medicaid
• Unable to pay medical
expenses for 2y
• Unexpected expense
↑ for ill / disabled /
aging family member
• Expect to claim child
denied Medicaid / CHIP
• Eligible for plan but not
enrolled due to appeals
decision
• Eviction / foreclosure
• Fire, flood, disaster
• Utility shut-off
• Domestic violence
• Close family death
www.hhs.gov
Types of Insurance
2014 Q2
Type of Insurance
Current / former employer
Self / family member
Medicaid
Medicare
Military / veteran
Union
Other
None
%
43.5
20.7
8.4
6.9
4.7
2.5
3.8
16.2
Gallup-Healthways-Well-Being-Index
Medicare vs. Medicaid
Medicare
Medicaid
Gov’t
Federal
Federal-state run by state
Eligibility
> 65
Disability
ALS: immediate
ESRD: 3mo post HD/CRT
Other chronic diseases
(if getting Social Security
Disability benefits for 2y)
Income
Categorical: peds, pregnant,
adult in family with dep peds,
disability, blind, older
Mandate: v low income, peds /
pregnant low income, most
disabled / older SSI cash assist
Homeless: 3rd party assistance
Coverage
Inpatient / outpatient care
Prescription drugs
Inpatient / outpatient care
Drug coverage optional but
provided by all states to most
Cost
Depends on coverage
Depends on income and rules
of state
Can have both (dual eligible)
www.Medicare.gov
www.medicaid.gov
Medicare Coverage
• Federal and state laws
• National coverage decisions made by
Medicare about what should be covered
• Local coverage decisions made by
companies in each state that process
claims for Medicare and decide what is
medically necessary and therefore should
be covered in that area
www.Medicare.gov
Medicare Parts
Part
What’s Covered
A
(Inpatient)
Hospital, skilled nursing, nursing home, hospice, home
health care (including visits / tests / procedures)
B
(Outpatient)
Services: clinical research studies, ambulance, mental
health, 2nd opinion before surg, certain drugs (infused /
injected by MD, EN / TPN, oral chemo / anti-emetics)
Supplies: EN / TPN, ostomy, neb, wheelchair / walker
Preventative: certain vaccines (flu, Pneumovax, HBV)
C
(Advantage)
Run by private insurance company (HMO / PPO)
Often lower deductibles / copays
Includes all Part A / B coverage, often prescription drug
May not cover non-medically necessary services
D
Each Part D plan has its own list of covered drugs,
(Prescription) premiums, deductibles, copays, coinsurance
Drugs not covered by Part B (self-injectable, Zostavax)
Pay extra $145-832 / year if income > $85,000
Max deductible $320 in 2015
www.Medicare.gov
The Dreaded Donut Hole
• Most Medicare prescription drug programs have
coverage gap: temporary limit on drug coverage
• Begins when spend $2,850 out-of-pocket
• Ends 1/1 of next year or $4,550 out-of-pocket
– “Catastrophic coverage” for rest of year: small copay
or coinsurance
• Includes deductible, copay, coinsurance, and
50% manufacturer discount payment on brandname drugs
• Excludes premium, pharmacy dispensing fee
• Once in donut hole, you pay 47.5% for brandname, 72% for generic drugs
www.Medicare.gov
Medicare with Other Insurance
• Coordination of benefits rules: >1 payer
– 1º payer pays up to limit of its coverage
– 2º payer pays only if there are uncovered
costs, but may not pay all of these
• Conditional payment
– Payment Medicare makes for services other
payer is responsible for
– Medicare makes payment so you are not
stuck with bill
– Your responsibility to make sure Medicare
gets repaid (call Benefits Coordination and
Recovery Center)
www.Medicare.gov
Medigap
• Medicare supplement insurance
• Sold by private company: pay premium
• Covers costs not covered by Medicare:
copay, coinsurance, deductible
• Must have Part A / B
• Cannot have Part D and Medigap for drugs
– Most Medigap drug coverage not creditable
(do not pay as much as standard Part D)
– May pay more if join Part D later
• No long-term care, vision / hearing / dental
www.Medicare.gov
Age 26
• Before ACA, insurance companies could
remove children at age 19
• With ACA, most must cover up to age 26
– Married, living / financially independent of
parents, school, eligible for employer’s plan
• Qualify for special enrollment period
• Get patients thinking about age 26 early
– Avoid missing doses / tests / office visits
• Other options if < 26
– Student, private, Medicaid, catastrophic
www.hhs.gov
Other Special Considerations
• End of year: plan renewal / change
– Starts October
– Patients who consumed much of your time
with authorization / denial issues need to
consider better plan (costs more)
• Loss of insurance / job
– Patients often know this is coming
– Advanced planning to get assistance
– Avoid missing meds and flaring
CCFA
• ccfa.org/science-and-professionals/programsmaterials/appeal-letters
• Bathroom accommodations (school / dorm, job)
• Social Security disability
• Patient financial assistance programs
– Meds
– Out-of-pocket expenses
– Ostomy supplies: Ostomy Group, Friends of
Ostomates Worldwide, United Ostomy Assoc
of America, Convatec, Hollister
CCFA
• ccfa.org/science-and-professionals/programsmaterials/appeal-letters
• Meds
– Dose escalation of anti-TNF
– Off label use
• Tests
– Fecal calprotectin
– TPMT, thiopurine metabolites
– IFX / HACA
– Capsule endoscopy
CCFA
• ccfa.org/living-with-crohns-colitis/talk-to-a-specialist
– Help center staff expert at answering questions and
finding resources
• ccfa.org/science-and-professionals/programsmaterials/patient-brochures
– Healthcare reform: fact sheet / update
– IBD insurance checklist: MDs, tests, meds,
supplies, services, expense sheet
– Employment and IBD: laws, accommodations,
FMLA, employment resources
• ccfa.org/assets/pdfs/resources
– Webinar (CCFA / CMS) on insurance marketplace
– Webinar on managing costs of IBD
Defeat Them With Data
• Anti-TNF dose escalation
– IFX: ACCENT I, IHIS, UPMC / Leuven, St. Clair
– ADA: CHARM, Billioud meta-analysis, BIRD
– CZP: PRECiSE 4
• Off-label use / dosing
– UST: CERTIFI, demand CD dosing, dose
escalation (cite anti-TNF data)
– GOL for CD: demonstrate prior response and
then LOR to all other anti-TNFs
– Tofacitinib: Sandborn
Defeat Them With Data
• Fecal calprotectin: Mao meta-analysis
• Thiopurines
– TPMT: Weinshilboum, Black
– Metabolites: Osterman, Dubinsky x2
• IFX / HACA
– Proactive (Cheifetz), reactive (Afif)
– Other: ACCENT I / II, SONIC, Baert, Maser,
Van Assche, Bortlik, Imaeda, ACT I / II, Seow
• ADA / AAA
– Karmiris (Leuven), Roblin, ULTRA 2
Hospital Assistance
• Social worker / financial counselor
– Help with access to insurance / medications
• Business administrator / pharmacy head
– Payment plans
– Copay assistance / coverage
– Can lower price of office visit to Medicare rate
– Bridge funding until have insurance
– Cost forgiveness for inpatient services
Pharma
• Most have patient assistance for underinsured
• Most have ties to charitable organizations for
uninsured (contribute money each year)
• IFX
– AccessOne: verification of benefits
– Remistart
• Only commercial insurance covering IFX
• Patient pays $50 per infusion
• Max $8-10K / year then Remistart Extended
– Medicare: Medigap, foundation assistance
– No insurance: J&J Patient Assistance
Foundation (income < 47K), other foundations
Pharma
• ADA
– Commercial insurance covering ADA
• Get $2,750-6,500 toward deductible
• After that, copay cards as low as $5 ($700800 / mo out-of-pocket expenses covered)
• Max $9,000 / year then Abbvie Patient
Assistance Foundation
– Medicare: Medigap, foundation assistance
• Unless Part D with retiree drug subsidy
– No insurance: Abbvie Patient Assistance
Foundation (income < 46K), other foundations
Charitable Organizations
• The early bird gets the worm
• Needy Meds
– Gateway to foundations
• Patient Advocate Foundation (CD, CRC)
– Copay / coinsurance / deductible
– Need insurance (commercial, Medicare)
– Income < 400% of federal poverty line
• Chronic Disease Fund (CD, CRC)
– Copay, transportation, lodging
– Need insurance (commercial, Medicare)
– Income requirements vary by state
Charitable Organizations
• Patient Access Network Foundation (IBD)
– Copay: max award for IBD $3,800
– Need Medicare
– Income < 400% of federal poverty line
• HealthWell Foundation (IBD)
– Copay / coinsurance / deductible / premium
– Need insurance (commercial, Medicare)
– Income < 400-500% of federal poverty line
• Nat’l Org for Rare Disorders (NORD) (IBD)
– Uninsured or underinsured
– Copay / coinsurance / deductible / premium,
travel, testing, consultation
Clinical Trials
• www.clinicaltrials.gov
• Trials with various therapies
– Old drugs
– Novel drugs
– Nutritional
– FMT
– Stem cell transplant
– Other (hyperbaric O2, yoga)
• Methotrexate for UC (MERIT-UC)
Persistence
• Persistence beats resistance
• Payers often obstructive and time drain
– RNs / MAs ready to provide documentation
– MD’s time is often weakest link
• Don’t give up: you can beat them
• Peer-to-peer review: call medical director
– Defeat them with data / expertise
– Consequences: hospitalization, surgery
– Make them squirm: put them in your place (if
patient were their child / parent / themselves)