High copays are an obstacle to health care

As our policymakers work on broad-scale health care reform from the halls of government, many physicians have joined patients in demanding change.

As a neurologist who sees multiple sclerosis (MS) patients every day, I am worried that without reform, our current system will kill preventive care and continue driving up the cost of care. I know this because patients too often tell me that they aren't taking their medications or aren't following my advice for maintaining their health because they can't afford skyrocketing copays.

Copays are the fixed, out-of-pocket costs required by health insurers to be paid by patients for services such as exams at a clinic, outpatient procedures, physical therapy and the filling of prescriptions. These services are often preventive in nature -- for instance, preventing paralysis that would otherwise need constant, long-term medical attention, or preventing hospital stays with visits to the clinic for doctor-recommended checkups.

The idea behind copays is to reduce wasteful treatments by patients and health care providers, thereby reducing costs. But some copays have gotten out of control. Preventive medications for MS patients fall into the "fourth payment tier," which are more expensive to produce because they are naturally, rather than chemically, derived. These treatments prevent MS attacks and lessen long-term disability.

Insurance companies recently introduced this highest-priced tier and are categorizing more medications into the fourth tier all the time. In many cases, the copay for an MS medication can jump from $25 to $200 for a one-month supply, effectively denying patients access to needed medicines and preventive care.

Rather than reducing costs, high copays increase total costs to the health care system. That's because a patient who is denied access to a needed medication has to see his or her doctor to come up with an alternative treatment. This results in lost time and productivity for the patient, and it wastes the time of the health care provider, who could be helping another patient.

The direct medical costs of an MS attack can be as much as $12,800, not counting increased physical therapy, home-care nursing and other costs.

This is a significant problem that affects many of the estimated 9,000 MS patients in Minnesota. A recent study by St. Paul-based Prime Therapeutics found that one in four MS patients is not filling his or her prescriptions because of higher copays.

State and federal policies are in development to help remedy the copay debacle and put patients' needs first.

In Minnesota, state Sen. John Marty, DFL-Roseville, and state Rep. Paul Thissen, DFL-Minneapolis, have asked the Senate and House health committees to develop cost-effective solutions to fourth-tier drug classifications. In addition, Minnesota legislators are considering a bill that would cap the cost of each MS drug at $50.

At the federal level, Sen. Al Franken has cosponsored a bill that would limit a patient's out-of-pocket expense to $200 a month for one prescription medication and $500 a month for all prescriptions combined.

Health care policies like these are an important step toward protecting patients with chronic conditions such as MS, and toward keeping them healthier for longer. This will ultimately save the system avoidable costs and keep patients looking to their doctors -- not their insurers -- for medical advice.