Report: Health Exchange patients may end up spending more on Rx medicines than employer plans

WASHINGTON — A new report by Milliman released Thursday found that Silver plans with combined deductibles offered through the Health Insurance Exchanges may require patients to pay more than twice as much out of pocket for prescription medicines overall as they would under a typical employer plan. This is a far larger increase in out-of-pocket costs than was found for other medical care, noted the Pharmaceutical Research and Manufacturers of America, which commissioned the study. 

With combined deductible plans, patients are responsible for 100% of their non-preventive medical and pharmacy costs before meeting the deductible. The findings reveal that the large combined deductibles for all medical spending that are common in Silver plans in Exchanges may disproportionately impact out-of-pocket costs for patients relying on prescription medicines. The report looks at Silver plans because they were the most popular in the enrollment period that ended March 31. 

“Americans participating in the Exchanges were promised coverage comparable to employer plans, and yet the reality is that many new plans are failing to provide an appropriate level of access to quality, affordable health care,” said John Castellani, president and CEO of PhRMA. “Patients face hurdles in accessing the medicines they need to manage their conditions, which is particularly problematic for Americans trying to control their chronic diseases.”

The Milliman report also noted that Silver plans are nearly four times more likely to have a single combined deductible for medical and pharmacy benefits (46% of the time) compared to typical employer-sponsored plans (12% of the time). This is an important distinction, particularly for patients with chronic illnesses, as it means prescription medicines are not covered until patients meet the deductible. According to Milliman’s analysis, the typical deductible for Silver plans is $2,000, PhRMA reported. Previous research from Avalere Health found that in the lower-cost Bronze plans, deductibles are even higher, averaging more than $4,000.

Further, the report concludes that Silver plans with combined deductibles impose 130% higher cost sharing for prescription medicine than typical employer-sponsored plans, compared to about a 20% increase for other healthcare services for members without subsidies who previously had typical employer coverage.

Studies have found that higher out-of-pocket costs reduce patients’ likelihood of taking prescription medicines to manage chronic conditions. The result is an increase in hospitalizations and higher healthcare costs overall. Conversely, programs that encourage better adherence have the potential to reduce emergency department visits, hospitalizations and other preventable, costly care. In fact, according to a 2012 Health Affairs study, improved medication adherence for patients with diabetes has the potential to save $8.3 billion each year.

“Medicines are one of the most significant contributors to improved quality and length of life for people with serious diseases, such as chronic illnesses, cancer and HIV/AIDS,” Castellani said. “To improve health and, in turn, control healthcare costs, we must continue to work toward a healthcare system that improves access and adherence to medicines.”