By Frank Oldham

President Obama’s healthcare reform is about to severely restrict drug treatment options for millions of America’s most vulnerable patients.

This certainly wasn’t the president’s intention. But a new, preliminary regulatory ruling from the Department of Health and Human Services required by the 2010 healthcare reform law applies a one-size-fits-all approach to prescription medicines. And the result could be substantially fewer treatment options for Americans all across the country.

Instead of requiring insurance companies to cover whatever medicine a physician deems appropriate, the HHS would only require them to cover a single drug in each class of pharmaceuticals. So for example, if an HIV patient reacted badly to a particular anticonvulsant, he could be out of luck trying to get another one paid for by his insurance plan.

If HHS’s preliminary guidance becomes law, it’s likely to harm patients and drive up healthcare costs. The proposed HHS approach is particularly problematic for patients living with chronic conditions, including HIV/AIDS, severe mental illness, diabetes, and cancer; covering just one drug is wholly inadequate to meet their complex needs.

There’s a way to do it better, making sure patients have access to the right medicines while keeping costs under control. In fact, we already have a model for how to make it work in Medicare Part D.

Implemented in 2006, Part D is a prescription drug benefit offered under Medicare, our system of government-subsidized health care for seniors. It requires competing insurance plans to cover nearly all drugs in six critical classes: immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.

Ensuring access to a wide range of drugs is particularly important for the HIV community. Every patient suffering from the disease exhibits unique symptoms, and it’s not uncommon for doctors to try a variety of drug regimens before determining the one that will work best. It’s also likely that patients suffering from chronic conditions, including HIV/AIDS, will require a combination of several drugs.

Furthermore, patients can easily develop hypersensitivities or adverse side effects from their first-line drug treatment. This is the case for many HIV antiretrovirals, which are known for their harsh side effects. In fact, it’s not uncommon for patients to take ten or more additional pills just to manage their side effects.

Patients can easily require multiple medications in more than one class of pharmaceuticals throughout their course of treatment. Covering just one drug per class will make it financially impossible for many patients to receive the cocktail of medicines they need, and may force patients to discontinue the most effective treatments.

Research into drug access for Medicaid beneficiaries also starkly illustrates just how dangerous restricted access to medications can be. Medicaid enrollees with problems accessing the drugs they need are far more likely to exhibit suicidal behavior, or experience homelessness and incarceration.

In addition to harming patients’ health, restricting the number of available drugs drags down our health care system. Patients whose conditions are not addressed by the single covered drug in each class are more likely to experience relapses in their illnesses, exacerbating symptoms and requiring more hospitalizations, re-hospitalizations and expensive acute care.

In fact, Medicaid beneficiaries with drug access problems are 74 percent more likely to visit an emergency room for treatment and when they do, tend to require 72 percent more acute inpatient days in the hospital. Annually, these hospital stays end up costing more than twice the annual spending on the prescription drugs that the patients should have been taking in the first place. It makes little sense to implement regulations that will cost more and increase the number of patients in hospital beds.

Part D, on the other hand, has been saving taxpayers and patients alike. The program’s costs have consistently come in below Congressional Budget Office projections. In fact, beneficiaries’ average monthly premiums for 2012 are lower than they were last year.

HHS will soon make its final ruling on what drugs insurers must cover. To protect patients’ health and control costs, it’s critical that officials revise their current, restrictive proposal. Instead, they should take a page from Medicare’s successful Part D.

Frank Oldham is President and CEO of the National Association of People with AIDS.


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