A bipartisan bill introduced in Congress last week aims to improve access to critical, and in some cases, life-saving drugs. The Patients' Access to Treatment Act (PATA) would significantly limit how much consumers pay for “specialty tier” – or Tier 4 – drugs, which include biologics that treat autoimmune forms of arthritis, as well as drugs for multiple sclerosis, cancer and other serious conditions.

For drugs in Tiers 1, 2 and 3, most health plans charge fixed co-pays, such as $10, $25 and $50. But increasingly, insurance companies are moving certain drugs – mostly biologics – into a specialty tier. Instead of a co-pay, patients are responsible for coinsurance, meaning they pay a percentage of the actual cost of the drug – sometimes 25 percent or even 50 percent.  

Biologics for rheumatoid, psoriatic and juvenile arthritis can range from around $1,000 to $3,000 per month. So, in the 25 percent cost-sharing model, the patient’s responsibility could be from $250 to $750 per month. PATA, sponsored by Reps. David McKinley (R-WV) and Lois Capps (D-Calif.), would end this practice of “discriminating between medications” with a fixed co-pay for Tier 4 that is in line with Tier 3.

“The current practice is unacceptable. The percentage that a patient owes should not be so large that he or she must choose between paying for critical medications or the mortgage,” says John H. Klippel, MD, president and CEO of the Arthritis Foundation.

Last year, the Arthritis Foundation and the American College of Rheumatology co-founded the Coalition for Accessible Treatments to tackle the issue of specialty-tier pricing. The Coalition, which now has 18 members – comprised of medical and patient advocacy groups including the American Academy of Neurology, Leukemia & Lymphoma Society and National Multiple Sclerosis Society – encourages physicians and others to ask lawmakers to support PATA in the 113th Congress.

Beyond easing patients’ pocketbooks, PATA would enable physicians to practice better medicine, says American College of Rheumatology president Audrey B. Uknis, MD.

“Our goal is always to treat the patients so that the disease is well controlled. We have the ability to advance therapy – to use, in some cases, safer and more effective therapy – but are prevented from bringing a patient together with the medicine that they need,” says Dr. Uknis, a rheumatologist and professor at Temple University School of Medicine in Philadelphia. “What prevents us from doing this at times is a prohibitive cost.”

Another challenge for both patients and physicians: knowing which drugs are in a specialty tier. In one plan, the anti-TNF biologic etanercept (Enbrel) is listed as a Tier 3 drug; in another, it’s listed in Tier 4. The same variability also applies to less-critical treatments such as hyaluronic acid injections, which are designed to cushion and lubricate joints affected by osteoarthritis.

“Different plans have different tiering based upon the negotiated pricing [with] pharmaceutical companies,” Dr. Uknis says. “[Physicians] can’t practice cost-efficient, quality care with our patients when we’re out of the loop on those [tiering] decisions or when they change.”

Some arthritis drugs, however, tend to be in Tier 4 consistently. These include some non-TNF biologics such as abatacept (Orencia) and the newest oral disease-modifying drug, tofacitinib (Xeljanz).

Susan Pisano is vice president for communication at America’s Health Insurance Plans (AHIP), the national trade association for the health insurance industry. She points out that pharmaceutical companies set the high costs of these drugs.

“The manufacturers charge a large fee and they rise quickly,” Pisano says. By further limiting how much insurers can charge consumers, “That makes insurance premiums go up – because it doesn’t address the fact that the manufacturer’s price of the drugs continues to go up.”

Amy Melnick, vice president of advocacy for the Arthritis Foundation, acknowledges that premiums would increase slightly, but because only a small percentage of the population requires Tier 4 drugs, “we don’t believe premiums will go up much.”

In fact PATA doesn’t apply to all Americans who need Tier 4 drugs – just those covered by commercial insurance, not those on government insurance such as Medicare.

Pisano says her organization hasn’t taken an official position on this bill – but that in the past, “we have not supported approaches that limit what you can do in designing a benefit without addressing the underlying cost of the drugs that are set by the manufacturer.”

Opposition from the health insurance industry is just one hurdle facing PATA, which was first introduced during the 112th Congress. “Ten thousand bills are introduced, and about 500 are passed. Getting this bill introduced with bipartisan sponsors in this highly contentious Congressional environment is itself a high hurdle,” Melnick says.

Other challenges, she explains, include Congress being focused on passing a budget – and having limited appetite for health care legislation after the sweeping Affordable Care Act passed two years ago.

The ultimate goal is for PATA to become law. “But first Congress requires Congressional hearings and bill passage in both the House and the Senate. Each of these steps represents its own legislative hurdle,” Melnick says.

For now, Reps. McKinley and Capps are working together to see the bill acted upon in the House Committee on Energy and Commerce, on which they both serve.

“Introduction of the legislation was the first step last Congress. Now I would like a hearing on the issue. Too many families are suffering; we should hear from patients, doctors and families on how this is affecting their lives and what we can do to make these treatments and therapies more available to people with insurance,” Rep. McKinley says. “Our office is looking to see how we can right a wrong for millions of Americans.”