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Oregon Patients Caught Between Insurers, High Cost for Specialty Drugs

Oregon Patients Caught Between Insurers, High Cost for Specialty Drugs [the Oregonian, Portland, Ore.]

From Oregonian (Portland, OR) (March 22, 2012)

March 21--About nine years ago Megan Helzerman, then 30, came to rely on a costly drug to treat the sudden onset of rheumatoid arthritis. With it, she can hike, cyle, even ski.

Without it is another matter. She feels tired all the time -- and the pain gets so intense that pulling on socks in the morning makes her cry.

Life without the drug is not an option, says Helzerman. But this year her cost jumped from $25 to $500 a month. Her insurance picks up the balance.

Helzerman is caught between two colliding health care trends: improved but exorbitant specialty drugs; and insurers and employers fighting escalating costs.

Behind Helzerman’s problem is the nationwide debate about the future of health care and whether the costliest drugs should be reserved for people who can afford to pay more for them. Instead of a fixed co-pay, patients pay a percentage of the drug’s cost, typically 20 percent or more.

Helzerman is fortunate. Her health plan caps her out-of-pocket to about $1,300 a year. "Most people are not quite that lucky," she says.

At issue are medications often known as "biologics" that target cancer, HIV, multiple sclerosis, hemophilia, hepatitis C, lupus and other chronic or progressive diseases. Specialty drugs generally impact a small population, and therefore cost a lot to recoup research costs, says Dr. Christopher-Paul Milne, associate director of the Tufts Center for the Study of Drug Development.

"We’re beginning to see this tension now where we’re getting targeted drugs," he says. "I don’t think they’ve quite figured out how to deal with it on the payment end."

Placing drugs in a "specialty tier" requiring patients to pay a percentage of cost rather than a flat fee is becoming more common. About 85 percent of Medicare drug plans do so, 25 percent of employers and 30 percent of health plans.

"It’s something that the employer can choose to try to control the premiums," says Steve Doty, owner of Portland-based Northwest Employee Benefits. He adds cost-sharing is the only way to solve the problem of health care cost. Insurers defend the change as a way they keep policies accessible to others.

"These were developed to keep coverage as affordable as possible," says Robert Zirkelbach, press secretary of the industry group, America’s Health Insurance Plans. He faulted pharmaceutical costs that are as much as $500,000 for a year’s treatment.

But studies show that many patients deal with skyrocketing cost by going off medications. And critics say that costs society more.

"It’s shortsighted," says John Motter, a former accountant in Portland who has HIV and hepatitis C. He says he pays about $10,000 a year for his medications, which saw steep increases in recent years. His medications save his insurer potentially higher costs down the road, including likely hospitalization and potentially a liver transplant.

Milne, of Tufts, tends to agree. "I think it’s somewhat incumbent upon (insurers) to figure out how to deal with it because these are drugs that should be able to prevent health care costs in other areas for these patients."

People like Motter and Helzerman found an ally in drug manufacturers seeking to limit patients’ costs for specialty drugs. Patient groups and the industry tried to pass a law in Oregon to ban specialty tiers last year, and hope to try again soon. A similar law passed in New York and bills have been proposed in about 20 other states.

Dianne Danowski Smith, a Portland public relations expert who works for the pharmaceutical company Pfizer and PHRMA, a pharmaceutical industry group based in Washington, D.C., has lined up patients like Motter to tell their stories.

"Obviously the pharmaceutical industry is interested in patients being able to access" their medications, she says.

Motter faults both drug manufacturers and insurers.

"I think there’s plenty of blame to go around," he says. "I’m 59, having to take money from my mother. My mom is 78. She could be using that money for other things."

-Nick Budnick


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Posted: March 2012