Tennessee’s largest health insurer is trying to save on the skyrocketing price of specialty drugs that require infusions or injections in a doctor’s office. But the plan has sparked such an uproar that full implementation has been put off until mid-year.
For more than two decades, Elisa Hertzan of Nashville has been trying to slow the march of macular degeneration.
“At the time I lost my first eye, we did not have any way of saving it,” she says. “Lucentis did not exist.”
Now, she gets monthly shots of this “miracle drug” directly into her good eye, and it’s working. Problem is, Lucentis runs about $2,000 per dose — one of many drugs that have insurance plans looking for savings. And so they’re going after the distribution process.
Her ophthalmologist orders directly from a distributor and keeps a bunch in stock at the office. Doctor’s offices bill insurance a fee for handling the drugs and generate some revenue by ordering in bulk and getting discounts they don’t necessarily pass along.
So BlueCross BlueShield of Tennessee is requiring doctors to only use their preferred specialty pharmacy which promises a 24-hour turnaround. But that’s not always fast enough for patients like Hertzan.
“There are times when I can’t read the numbers on my alarm clock, and I know something is wrong,” she says.
She gets her neighbor to summon a ride-hailing service that takes her directly to see Dr. Carl Awh at Tennessee Retina.
“A lot of retinal diseases are fast moving, and delays in treatment will result in lost vision,” he says.
Awh says he depends on the flexibility of having his own supply of these drugs. He concedes patients could possibly wait a day without major problems, but scheduling isn’t that simple.
“If I see you on a Tuesday, and I tell you that you can’t be treated that day, ‘Please come back.’ Your schedule is full at work on Wednesday,” he says. “It’s not just that you can come back the next day.”
Awh isn’t worried about just a few patients. Tennessee Retina now does roughly a hundred of these shots every weekday.
“It has become a huge percentage of what we do in terms of our time spent,” he says. “It’s changed the nature of being a retina specialist, but really so much for the better in terms of what we can do for our patients.”
Macular degeneration is just one of many conditions that can now be treated with expensive specialty drugs. Others include rheumatoid arthritis, multiple sclerosis and cancer. And the practices most affected are putting up a fight, saying patients will be harmed in the process to save a few dollars.
But BlueCross chief spokesman Roy Vaughn says emergency injections are rare and the insurer is working on a solution for them. Otherwise, he says practices will just have to adapt.
“We’ve tried to design this in such a way that it mirrors with what they were doing already,” Vaughn says.
The state’s dominant commercial insurer insists that doctors are just defending a substantial revenue stream. BlueCross expects to save 20% on specialty drugs, just by using its preferred company. And Vaughn says those savings will largely be returned to employers, who pay the bulk of prescription insurance costs and feel like they’re growing unsustainably.
BlueCross says specialty drugs represent 1% of all prescriptions but will end up being fully half of the cost this year.
“There are more of these drugs than ever before, and more of them are in the pipeline,” Vaughn says. So the trend is not going away.”
This new policy, now set to fully take effect in July, involves 100 large employers, which are self-insured, including the state of Tennessee. BlueCross has set up a website to help answer patients’ questions. But insurers across the country are taking similar steps to rein in drug spending.
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