POINT OF VIEW Scant protection offered for autoimmune patients


Researchers are discovering new potential ways to treat a number of autoimmune diseases, such as scleroderma and lupus, that affect hundreds of thousands of Americans. Novel treatments are being investigated that will help restore the health and productivity of these affected patients.

Unfortunately, even if researchers are successful in developing new treatments for scleroderma and other related autoimmune disorders like rheumatoid arthritis, patients may not benefit. In response to rising health care costs, insurers are increasingly rationing access to treatments and doctors. As a result, patients are growing sicker, which ultimately increases health care costs.

Costs are rising at a worrying pace. America currently spends about $3 trillion on health care. From now until 2025, health spending will grow an estimated 5.8 percent each year.

So it’s at least understandable why insurers are employing every possible tactic to keep their costs down. However, most of their efforts don’t actually avert spending — they just shift the burden onto patients, or into the future.

Insurers increasingly require patients to pay a percentage of the total cost of specialty drugs, rather than a fixed co-pay. These medicines often are the most effective treatments for autoimmune disorders. Patients with rheumatoid arthritis can face out-of-pocket costs of $500 to $5,000 a month if they need these necessary specialty drugs.

Insurers are also raising deductibles. From 2006 to 2015, the average deductible rose from $303 to $1,077 for those on employer-sponsored health plans, according to the Kaiser Family Foundation. Many rheumatoid arthritis patients typically have to spend more than $2,500 before coverage kicks in.

Insurance companies are also restricting which doctors or hospitals patients can access.

For example, when one Texas couple purchased a Blue Cross plan through the federal package, they found that many of their specialists were no longer in-network. The wife, who suffers from rheumatoid arthritis, lost access to her specialist. She has yet to find an in-network specialist within 100 miles of her home.

Such limited coverage of specialists is the norm, not the exception. About 70 percent of exchange plans cover fewer than a quarter of all the physicians in a given area.

The high cost-sharing requirements and insufficient coverage of specialists mean that many autoimmune patients can’t afford to seek care. Going without treatment poses a serious risk. Untreated rheumatoid arthritis can lead to complications ranging from progressive disability, to increased risk of infection, coronary artery disease, and even malignancies.

Those complications ultimately cost more than what regular doctor visits and drug regimens would have cost. Coronary artery disease, for instance, can cost more than $17,000 in a patient’s first year of treatment.

The current insurance system demands too much of patients. Most Americans can’t afford to pay thousands of dollars a month in out-of-pocket expenses or travel hundreds of miles to see a doctor. Limiting insurance expenses would keep patients healthier and curb long-term health spending.

MICHAEL SCHWEITZ, WEST PALM BEACH

Editor’s note: Dr. Michael Schweitz, a rheumatologist, is past president of the Coalition of State Rheumatology Organizations.



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