Study finds unfair HIV-drug pricing in US health plans

MIAMI: Some US health insurance plans are discriminating against people with HIV by placing antiretroviral drugs in a high-cost category and forcing patients to pay more for coverage, researchers said Wednesday.

The study in the New England Journal of Medicine warns that the practice is undermining a key provision of President Barack Obama's health care reform, which set out to end health insurers' use of preexisting conditions to deny coverage to sick people.

Under some health plans, HIV drugs may cost a patient nearly $3,000 more per year than in other plans, said the study led by Harvard University.

"Eliminating discrimination on the basis of preexisting conditions is one of the central features of the Affordable Care Act (ACA)," said lead author Doug Jacobs of the Harvard T.H. Chan School of Public Health.

"However, the use of formularies to increase costs and dissuade those with preexisting conditions such as HIV from enrolling in the plan threatens to at least partially undermine this goal of the ACA."

The practice that Jacobs and his colleagues identified is called "adverse tiering," in which all drugs for certain conditions are placed in the highest cost-sharing tiers.

Researchers studied 12 states that are part of the nationwide federal marketplace for health insurance.

Six of the states analyzed were mentioned in a legal complaint to the Department of Health and Human Services for alleged adverse-tiering: Delaware, Florida, Louisiana, Michigan, South Carolina and Utah.

Researchers also looked at six heavily populated states that did not have any of the insurers implicated in the complaint, including Illinois, New Jersey, Ohio, Pennsylvania, Texas and Virginia.

About one quarter of the plans examined used discriminatory drug tiering for one of the most common classes of HIV medications, known as nucleoside reverse-transcriptase inhibitors (NRTIs).

"We found evidence of adverse tiering in 12 of the 48 plans - 7 of the 24 plans in the states with insurers listed in the HHS complaint and 5 of the 24 plans in the other six states," said the study.

"Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans."

People who enrolled in adverse-tiering plans (ATPs) paid on average three times more for HIV medications than people in non-ATP plans, with a nearly $2,000 annual difference even for generic drugs, according to the study.

Despite the generally lower annual premiums associated with adverse-tiered plans, customers with HIV paid an average of $3,000 more for treatment per year than they would have under a non-ATP plan.

The researchers warned that the practice could put significant financial strain on ill people and could "lead to sicker people clustering in plans that offer more generous prescription drug benefits -- which could in turn create a 'race to the bottom' in insurers' drug plan designs as they try to avoid a large influx of sick enrollees that would negatively affect profits."