Category: Professional Posters
Purpose: Almost half of adults younger than 65 have high-deductible health plans (HDHPs) which require them to pay the full cost of medications and treatment until their deductible is met. Patients with HDHPs are far more likely than those with traditional plans to forgo or delay needed care due to high upfront costs and confusion about their financial responsibility throughout the year. This project was designed to determine differences in out-of-pocket (OOP) costs between two insurance plans and propose practical tips that pharmacists can employ to improve medication use among patients by personalizing health care cost conversations.
Methods: A pharmacist and clinical nurse case manager utilized aggregate data from Patient Advocate Foundation’s case management program to create a breast cancer patient profile. Cost implications for medications and other covered services and procedures were compared between two typical insurance plans offered by employers: traditional preferred provider organization (PPO) and a HDHP. Treatment selections were based on peer-reviewed clinical practice guidelines such as the National Comprehensive Cancer Network (NCCN) guidelines. OOP costs for each treatment and service were estimated using Healthcare Bluebook and the insurance plan’s benefit design for a 45-year-old female receiving in-network treatment in Washington DC. A series of experiments were performed to simulate the expected annual and monthly OOP costs pursuant to a PPO or HDHP across three scenarios with diagnosis and treatment initiation in: January at the beginning of the plan year, July (mid-year) and November near the end of the plan year. Non-medical living costs including food, housing and transportation were layered upon health care costs to illustrate the financial liability a patient would experience every month throughout the course of treatment. The team hypothesized that under the conditions described above, the traditional PPO plan would be more cost effective than a HDHP, potentially spreading OOP costs throughout the year.
Results: The patient’s financial obligations for health care spanned 24 months or two plan years in the first scenario and 36 months or three plan years in the second and third scenarios. Contrary to our hypothesis, total annual health care costs including premiums and OOP spending were greater under a PPO plan by approximately $3,000 for a majority of plan years. Total annual costs were greater under a HDHP only in one plan year when treatment was initiated in November. Across three scenarios, the patient would experience higher monthly OOP costs for a greater number of months in the PPO plan compared to HDHP. OOP costs were concentrated among two to four months of the year in the PPO plan and among one to two months of the year in the HDHP. Monthly health care costs would likely place substantial financial stress on the patient’s ability to afford non-medical living costs. The financial impact of treatment and services were directly influenced by the diagnosis date within an insurance plan year.
Conclusion: A patient’s ability to afford and adhere to treatment is dependent on insurance plan selection prior to diagnosis. This illustrative case highlights the nuances of insurance benefit design and how one treatment plan could have two substantially different financial obligations. Pharmacists as members of interdisciplinary care teams are positioned to serve as conduits to financial and safety net resources. As HDHPs continue to gain popularity and policy solutions move towards improving health care cost transparency, pharmacists have a unique opportunity to educate patients about their health insurance options to improve medication selection and adherence as well as minimize financial distress.