PPA Joins Patients in Harrisburg to Advocate for Access to Meds

Marion Mass, M.D. asks lawmakers to “roll up their sleeves” and work with physicians on behalf of patients

Non medical switching happens when a patient is changed to a different medication because the PBM-imposed formularies, the drugs that are covered by insurers have changed. On Feb 18, 2020, PPA’s Marion Mass, MD stood beside patient advocates and gave testimony to The Consumer Affairs Committee of the Pa State House regarding Non Medical switching. Highlights below.

Mass’s testimony excerpts:

“I thank you for this opportunity to testify on behalf of Pennsylvania patients. Other than practicing as a pediatrician in Bucks and Montgomery County of Pennsylvania, I have no conflict of interest.  I paid my own way to come here today, as I do for every advocacy trip.

House Bill 853 is vital to protecting the health and well-being of patients, especially those with serious chronic medical problems. Patients, especially those with chronic illness and preexisting conditions,  deserve consistent benefits during the tenure of their insurance plans.

Let me start with a story.  Ryan was diagnosed with complex partial seizures at age 17, and for most of the last 20 years he has been well controlled on Topomax and Lamictal.  Initially, he had excellent coverage for brand names of both, but his out of pocket cost for the brand name shot up suddenly and unexpectedly to $320 for a 3 month supply, compared to $10 for the generic.   Ryan switched to generics three separate times during the middle of the policy year.  With two of the three switches, he suffered breakthrough seizures.  For those listening who are unaware, having a seizure not only is a life-threatening event while driving a car, or operating any mechanical or sharp implements, a breakthrough seizure prevents epilepsy sufferers from driving for 6 months.  He also suffered accentuated side effects of memory decline and dizziness, and intense worry of having a seizure at a dangerous time. These were affecting his personal and professional life.  Ryan is a staunch self advocate.  During the time of trying to advocate to get back on brand name, he suffered the disruptive and frustrating process of having to make multiple calls per week, lasting upwards of 30 minutes to his insurance company.  

There are 133,000 epileptic  patients in Pennsylvania.  There are 7.7 million patients with at least 1 chronic disease, and almost half of those have more than 1 chronic disease most necessitating medication. 

  Not all of those patients can advocate as well as Ryan.  Non-medical switching is dangerous to their health, and destructive to their well-being as well as their pocketbooks.

I have seen dozens of affected children personally and am here to tell this committee, and all of Pennsylvania that we must protect treatment decisions made between physicians and the patients for whom they care so that patients get the appropriate access that they deserve at a reasonable cost.

During the questioning, I am happy to reveal more specifically what I know regarding drug pricing, formulary switching and pharmacy benefit managers.  I can share citations from other states that have advanced legislation and have studies regarding the dangerous practice of non- medical switching.

For Pennsylvanians who are living with chronic health conditions, coverage changes allowed by non-medical switching can devastate health and finances. Coverage, when purchased, must remain fair and consistent –patients cannot change plans during the policy year, insurers should not be able to change formulary coverage during the policy year for treatments and services the patient is receiving. It’s time for this committee and all policy makers to think of patients first.  Just like you, did, physicians took an oath… ours was to protect patients.  Let’s roll up our sleeves and do that…. Together. ”

Angie Santiago, lead financial counselor, oncology, Thomas Jefferson University Hospitals, said her job includes helping patients understand what is covered by their health insurance as well as options for additional financial support. She noted that her hospital’s cancer center started having problems with non-medical switching about 18 months ago. She explained that non-medical switching allows insurers to re-categorize prescriptions as pharmacy benefits, requiring the prescription to be filled through a specialty pharmacy outside of the hospital. The switches are also able to occur in the middle of the plan year, preventing patients from switching their health plans, she said. She shared the story of one patient who had to change how he received and paid for his medicine in a few weeks in order to continue to receive his chemotherapy treatment. 

Robert Mentzer, advocate, shared his firsthand experience of non-medical switching when his daughter, who suffers from epilepsy, had her medication switched to a generic version, causing her to have a severe seizure. He explained that when his daughter’s medication was removed from coverage, his family had to choose to either switch to the generic version or pay the $3,250 out-of-pocket cost for the brand prescription. 

Sam Marshall, president and CEO, Insurance Federation of Pennsylvania, noted that health plans provide notice of any change in the drug formulary to allow a doctor to explain why the patient needs to remain on that particular medication. 

Arielle Chortanoff, government affairs director, Independence Blue Cross (IBX), said negative formulary changes are limited and require a 45-day notice to members with appeal rights available. . She noted that the bill fails to address the issue of cost

Dr. Mass said the amount of paperwork that patients and physicians receive from insurance companies and the process of completing these appeals take away from patient care. Chortanoff responded that insurers are developing tools to make it easier for physicians and patients to understand benefits and alleviate the paperwork burden. 

Rep. Oberlander asked Dr. Mass if she had any experience with issues related to diabetes. Dr. Mass said insulin is typically covered to treat diabetes. She added that there’s no transparency on the money flowing between pharmacy benefit managers and pharmaceutical companies despite Pa’s Auditor General Eugene DiPasquale asking for this transparency. Mass later pointed out that Pharmacy Benefit Managers(PBM) are now owned or own insurance companies, and that PBM in a shocking conflict of Interest have the right to receive money from drugmakers. “In any other industry, this would be a kickback” Mass stated. It would be illegal, but kickbacks are legal for PBM and their hospital counterparts the GPO.  

Rep. Neilson asked for more information on the panels making these decisions. Yantis said formulary changes are decided by a group of physicians and clinicians who meet quarterly to review drugs coming into the market and compare them to the drugs currently on the formulary to make recommendations to the Highmark pharmacy team on the best tier for that drug. Dr. Mass said large pharmacies like CVS own pharmacy benefit managers and could create their own panel (with in-house pharmacists) to make decisions. She again noted that pharmacy benefit managers are allowed to accept monetary remuneration from pharmaceutical manufacturers. Rep. Neilson asked if anything has been done legislatively to prescribe how those panels are put together. Yantis said they are put together based on best practices and not a state or federal regulation. 

Doug Furness, senior director of legislative and regulatory affairs, Capital Blue, and Michael Yantis, vice president of state government affairs, Highmark, also testified.

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