Ongoing medical conditions need ongoing insurance coverage

Photo by Reynaldo Leal

There is growing concern that many Texas health insurance policyholders do not receive the care their insurance providers promised them. Two bills, now before the Texas Legislature, will make sure doctors – not insurance company cost cutters – decide what treatments patients receive.

Health insurance is a pretty straightforward proposition: the policyholder agrees to pay a set premium each month, and in return, the insurance company pledges to pay for certain medical treatments. Policies spell out what medications will be covered.

Even though Texas legislators have taken steps to protect patients, insurance providers can – and do – still engage in a practice called “non-medical switching,” where patients’ prescriptions are changed to other, more profitable treatments. 

Here’s how it works: at the end of a plan year, the insurance company can either drop a previously-covered drug from their list of approved medications or raise the co-pay to a level so high that it becomes unaffordable for most people. As a result, patients find that the medicine their physicians prescribed for them is suddenly no longer available or affordable. At other times, when patients are treated in health care facilities such as the physicians’ clinics or infusion suites, insurance companies may deny certain approved biological therapies and force the healthcare providers to go through extensive appeal processes to switch to cheaper alternatives, without any knowledge or consideration of medical necessity or previous patient experience. The consequences of this unfair practice can be devastating.

Every patient is unique. It can take years for patients and their doctors to find the right stabilizing treatment, particularly for patients with chronic conditions like epilepsy, arthritis, cancer, mental illness, chronic pain, HIV/AIDS, Lupus, hemophilia, or immune deficiency diseases with chronic inflammatory symptoms. When that drug is no longer available or affordable because an insurance provider refuses to continue paying for it, patients and doctors must start over again. For those patients suffering from serious, long-term illnesses, losing access to their medication can mean a return of symptoms, or even new, serious side effects caused by the replacement therapies. 

Pinpointing a new drug that puts a patient’s life back in order – if a viable alternative treatment is even out there – can mean additional doctor appointments, hospital stays, emergency room visits, not to mention additional suffering by patients. It is difficult for patients and their physician partners who have already gone through this process once; and it can be dangerous, since it may cause serious implications for the patient’s health.

It is also expensive. The total costs accrued in finding a replacement drug therapy to try to restore stability often exceed what the insurance company would have spent had they just let the patient stay on the original medication. In fact, several studies found that patients with conditions like diabetes, hypertension, congestive heart failure, epilepsy and rheumatoid arthritis experience up to twice as many hospitalizations in the months after a non-medical switch.1,2,3

The Texas Legislature has addressed this issue in the past, but the rules they adopted only protect patients against non-medical switching in the midst of the policy term – for only one year. House Bill 2882 and Senate Bill 1967 would extend that protection for as long as policyholders pay their monthly premiums.

That’s the only fair way to do it. Patients with ongoing conditions need ongoing coverage – the coverage they were guaranteed they would receive when they bought their policies.

Texans, who pay their hard-earned money for their medical insurance, have a legitimate right to be stable and remain on the medication that works for them. If the Legislature approves House Bill 2882 and Senate Bill 1967 – and I urge all Texans to join me in asking our state lawmakers to do just that – insurance companies will have to live up to their responsibility to give patients the medical stability they pay for and deserve.

Daniel Suez

Immunologist

1 Comment
Ongoing medical conditions need ongoing insurance coverage Show All