Opinion

Specialty Tiers Put Crucial Therapies Out of Reach for Millions of Patients

It seems obvious that when medical innovation allows us to combat or cure diseases once thought untreatable, we should use it.  And when given the choice to preserve a family, to improve life and to empower Americans to overcome illness, we should embrace it.

But for a special class of drugs, this simply isn’t the case. Spiraling copays keep these vital therapies out of reach for millions of insured patients, just because their pockets aren’t quite deep enough.

As a practicing rheumatologist, I have witnessed incredible progress in the way we diagnose and treat rheumatic diseases.  Most notably, unprecedented drugs called biologics now have the ability to target specific aspects of the immune system that cause rheumatoid arthritis, the nation’s leading cause of disability.

By utilizing biologics, rheumatologists can now prevent disability and serious illness, allowing patients suffering from rheumatic diseases to maintain important daily functions, remain in the workforce and contribute fully to society.  Not every patient with rheumatoid arthritis needs a biologic – but when they do, it is because no other medications will work. While biologics represent the best of American biomedical innovation, their elusive nature illuminates one of the most pernicious flaws in our healthcare system – enormously high costs that make treatment out of reach to the average insured American.

This is the result of inadequate policies adopted by many commercial health insurers, under which they move vital biologics into so-called “specialty tiers.” Historically, the average patient has been required to pay a fixed co-pay for medications, such as $5 for generic (Tier I), $25 for preferred brand-name (Tier II), and $50 for non-preferred brand-name drugs (Tier III).

Specialty tier drugs now transcend the traditional tier system, shooting certain copays way up. Instead of paying a fixed cost, patients are expected to pay a percentage of the actual cost of biologics that have no cheaper generic alternative. With the annual cost of biologics ranging from $12,000 to $48,000 or even more, patients end up with copays that can easily reach into the thousands of dollars every month.

For the average American, such an expense is completely unaffordable. It forces patients to ask themselves if they should pay thousands of dollars every month to prevent their disease or disability from worsening, even if it means serious financial debt.

At the American College of Rheumatology, we believe that this question should be out of the question. No patient should be forced to decide against the best available treatment for rheumatoid arthritis or other rheumatic diseases. In fact, no patient who could medically benefit from biologics – such as those with lupus, multiple sclerosis, some forms of cancer, and primary immunodeficiency diseases – should be forced to decide between physical and financial health.

For that reason, we wholeheartedly support the Patients’ Access to Treatment Act (PATA). This bipartisan legislation, introduced by Rep. David McKinley (R-W.Va.) and Rep. Lois Capps (D-Calif.), would limit the co-payment, co-insurance, or other cost-sharing requirements levied on patients who require specialty medications to treat life-threatening or chronic diseases.  More specifically, PATA would prevent the price of specialty drugs from exceeding the dollar amount of prescription drugs in a non-preferred brand drug tier, guaranteeing greater affordability.

PATA would also provide long-term cost savings for our healthcare system. By helping patients access crucial medications, we can prevent a range of costly scenarios down the road, including disability, unnecessary hospitalizations, surgeries and other costly outcomes. Moreover, it will allow millions of Americans to work longer, support their families and contribute to our economy.

This legislation represents a rare economic win-win for both patients and healthcare by reducing patients’ costs and generating measurable savings for our nation’s healthcare system.

We have life-changing drugs at our disposal that can save money and improve lives. Now we need to make sure patients can afford them. The first essential step is passing the Patients’ Access to Treatment Act (H.R. 1600).


Will Harvey, M.D., is Chair of the American College of Rheumatology Government Affairs Committee. 

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