A Report on Non-Medical Switching in Tennessee

2016-12-20 | CSRO Executive Office

Non-medical switching can be a harmful practice that many patients are unaware of, and fall victim to. This happens when insurers force a new medication on a medically stable patient for non-medical reasons, exiting from their current successful medication that may have been dropped in a changed plan. New out-of-pocket costs can also force unproven medication on a patient for non-medical reasons, and this switch can have dismal consequences. Formularies can be changed at any time, and these changes can occur in the middle of the year when contracts are non-negotiable. It leaves patients without the benefits that they initially received in their plan.

Non-medical switching can bring many harmful results aside from the harm caused to the patient’s relationship with their physician. Diseases can worsen, and alternative medicines can develop side effects. Recently, the Global Healthy Living Foundation (GHLF) surveyed Tennesseans living with chronic diseases about the frequency of nonmedical switching and its effects.

Using a diverse group of 85 residents that had all types of insurance coverage, the survey produced an accurate perspective of the state’s chronic disease patients. Shockingly nearly three out of five respondents reported a health plan’s changed formulary that dwindled coverage of their prescribed medication. Primary medications became greatly more expensive, and it was found that patients were more likely to have their coverage reduced for autoimmune disorders than for medications for any other condition.

More than 65% of respondents were unable to afford the increase in out-of-pocket prices and were forced to switch to a different medication. 40% of respondents reported that their insurance company tried to persuade them to change their clinician-prescribed medication for nonmedical reasons. When a formulary was changed and resulted in loss of coverage, nearly half of respondents said their ability to access or obtain their prescribed medication was delayed.

These statistics are eye-opening, and they result in negative health consequences. 95% of respondents in Tennessee reported worsening symptoms when a changed formulary delayed their medicinal access, which then resulted in 39% having to miss some work, and 22% having to be hospitalized.

Furthermore, communications about formulary changes to patients does not seem to be important to third-party payers. Almost half (44%) of survey respondents said they had never received any notification about their plan’s switch. Many respondents (52%) received notice from their pharmacist or physician. Only 28% said their insurer was transparent about changes being made primarily for cost concerns.

GHLF’s survey displayed how common non-medical switching has become in Tennessee. Treatments for rare and chronic diseases are being delayed or eliminated, increasing the number of hospitalizations, doctors’ visits, and so on, thereby increasing overall costs.

With no state protections in place in Tennessee at this time, legislation is required to protect consumer patients so they can enter contracts that will be honored and their health can be maintained. GHLF suggests patient protections that deem that, outside of open enrollment periods, an insurer cannot:

  • Remove any covered prescription drug from its formulary during the health plan year unless the FDA has issued a statement about the drug that calls into question its safety
  • Reclassify a drug to a more restrictive drug tier or to a higher cost-sharing tier during the health plan year unless a generic equivalent becomes available
  • Reduce the maximum coverage of prescription drug benefits

To help curb non-medical switching, the CSRO has joined many newly formed state coalitions, like the Tennessee Patient Stability Coalition, that will look to educate and legislate on behalf of patients in 2017. For more information on the survey data, please visit creakyjoints.org.

Website Designed and Maintained by
WJ Weiser & Associates, Inc.