To reduce costs and maximize profits, insurance companies are increasingly denying coverage to patients treating chronic or persistent illnesses — such as cardiovascular disease, diabetes, autoimmune diseases like rheumatoid arthritis, and cancer. But for the chronically ill in particular, trying to save costs by denying treatment coverage just worsens patient health and increases the lifetime cost of caring for these patients.
As many as 53 million insured Americans with chronic illnesses or conditions may be at risk of being denied coverage for a prescribed treatment, according to a recent survey commissioned by the Doctor-Patient Rights Project, or DPRP. Disclosure: We’re founding members of this new coalition of doctors and patients who feel strongly about returning decision-making to those who know best — doctors and patients.
[See: How to Pick a Health Insurance Plan.]
DPRP recently commissioned a national study of 1,500 patients with insurance, which found that insurers denied coverage to nearly 1 in 4 patients treating chronic or persistent illnesses or conditions. Over 70 percent of the denied treatments, moreover, were for conditions described as “serious,” and 43 percent involved patients who said they were “in poor health.”
While insurers cannot restrict any patient from receiving a treatment their doctor prescribes, they can withhold coverage, which effectively blocks access to treatments for most patients. According to DPRP’s survey, more than a third of denied patients — nearly 23 million insured Americans — may have to put off or forego treatment of their chronic condition because they cannot afford the expense on their own.
Even worse, DPRP uncovered that most patients denied treatment coverage for a chronic or persistent illness waited over a month for their insurer to make a decision. For 28 percent, the wait was three months or longer. While they waited, nearly a third (29 percent) of these patients watched their condition worsen. For people with a disease like familial hypercholesterolaemia, which is an inherited disease that leads to aggressive and premature cardiovascular disease, there are new treatments called PCSK9-inhibitors which have been proven to drastically lower LDL cholesterol (the one diet can’t help). Imagine having a loved one with FH whose LDL is dangerously high and, without treatment, could perish from a heart attack or stroke. Now imagine how it feels for those delays — one, two, sometimes three months — for an insurer to process the request and pay for the medicine.
Disgusting.
The American health care system was designed to treat patients with acute illnesses, sudden conditions that usually can be cured with swift and appropriate treatment. A growing number of patients in the U.S., however, are treating chronic conditions, persistent, progressive diseases that require ongoing medication. As the Society of Actuaries put it: People “come down” with an acute illness; they “develop” a chronic condition.
[See: How to Help Aging Parents Manage Medications.]
Health insurance companies that believe they can save money by denying coverage for chronic conditions mistakenly view treatment costs through the prism of acute illness. Refusing to cover a treatment prescribed for a patient facing continuous out-of-pocket pharmaceutical costs either prevents them from starting a medication or interrupts the prescribed course of treatment. One survey of Medicare beneficiaries, for example, found that more than three-quarters of patients who did not have a prescription filled reported that they did not adhere to the medication schedule because their medicine was not covered by insurance and they thought it would cost too much.
Delaying or denying treatment of chronic diseases merely allows them to “develop” the longer they are neglected. When patients with chronic illnesses do not receive treatment, or when they skip doses because of cost concerns, their diseases progress more quickly and their health worsens, according to research from the Kaiser Family Foundation and the Center for Medicare and Medicaid Services. One recent study, for example, found that breast cancer patients who skip post-surgery medications because of high co-payments were more likely to experience a recurrence and less likely to survive.
Doctors make treatment recommendations on the basis of medical science and sound clinical practice. That may be why more of the patients DPRP surveyed indicated that they trusted there doctor more than anyone else — even themselves — when making treatment decisions. Presumably, a doctor prescribes a treatment for a chronic illness because it’s essential to a patient’s care.
Nevertheless, almost a quarter of patients denied treatment coverage were told by their insurance company that the prescribed treatment was medically unnecessary. Little wonder that the greatest consensus of patients DPRP surveyed — 9 in 10 — supported the idea that insurance providers should not have final say in treatment decisions. Nearly 4 in 10 thought insurers should play no role in the decision process at all.
[See: 7 Innovations in Cancer Therapy.]
Insurers who refuse to pay for medications prescribed to treat chronic illnesses are not only are sacrificing the health of their patients, they are increasing the cost of care for patients whose diseases progress in the meantime. Penny-wise, pound-foolish. Patients suffering from chronic or persistent illnesses pay the same premiums as those who experience acute conditions. They deserve the care their doctors say they require.
More from U.S. News
How Hospitals Are Using Technology to Become More Patient-Centered
10 Lessons From Empowered Patients
The Most Common Patient Complaints
How Insurer Denials Hurt Patients and Industry originally appeared on usnews.com
