When we broke the story a couple weeks ago that Kaiser Permanente had moved HIV medications to a "specialty tier" �" requiring patients to pay about 20 percent of the cost rather than a less expensive copay �" we didn't think the health care company would respond so quickly, let alone agree to remove the drugs from the costly tier and refund patients who had already paid for their prescriptions. But after meeting with gay District 8 Supervisor Scott Wiener, that's exactly what Kaiser did and it deserves credit for its rapid response. After our story ran, but before Kaiser announced its reversal, there were reports that other insurance companies had done the same for drugs that treat depression and other illnesses. When someone has to pay $900 or $1,000 a month for prescriptions, it becomes a personal financial burden with health consequences; people will stop taking the medication as directed, splitting pills or not taking them as often in order to extend their supply.
Also alarming was that most people were unaware of the prescription payment change until they refilled their medications and were presented with a high co-insurance payment. Apparently Kaiser made little effort to alert patients about the dramatic jump in costs.
Significantly for the HIV/AIDS community, Kaiser is a participant in the city's Getting to Zero coalition, which promotes an aggressive plan to cut new HIV infections by 90 percent by 2020. The health care giant sees about one-third of people living with HIV in the city and must coordinate its large patient base with UCSF, medical providers, and the city's health department to implement the plan. Getting to Zero also relies on people getting tested and into treatment if they test positive. It would have been counterproductive if HIV drugs had remained in the more costly tier; people might have gone off of treatment, which could potentially result in more HIV transmissions.
Pre-exposure prophylaxis, or PrEP, is a key component of Getting to Zero. A month's supply of Truvada, the drug approved for PrEP, runs about $1,000. Now that PrEP is covered by most health insurers, it, too, needs to be accessible to patients and not out of reach in a higher price bracket.
Health department officials told us a few months ago that Getting to Zero requires buy-in from the community, particularly gay men who account for the majority of new HIV cases in the city. It's impossible to see how higher drugs costs will garner community support. To make Getting to Zero work, more HIV-negative men need to be on PrEP, more people need to get tested for HIV, and medication must be set at realistic prices.
The development of these specialty tiers is an unwelcome side effect of the Affordable Care Act; as health insurers are mandated to provide insurance plans for everyone, they need to maintain their profit margin and increasing prescription payments is one way to do that. Ultimately, however, this is not in the best interests of patients, as Kaiser was quick to realize.
Wiener told us that he's still going ahead with a hearing on these specialty tiers and that's important. The other insurance companies all have them, from which they need to remove popular and effective drugs, especially those used to treat HIV. Medication for hepatitis C is also outrageously expensive, to cite another example.
State lawmakers are also paying attention to the issue. Bills by Assemblymen Rich Gordon (D-Menlo Park) and David Chiu (D-San Francisco) would offer some relief. Gordon's Assembly Bill 339 would define and limit the specialty prescription drugs that are subject to high cost-sharing. Chiu's AB 463 would require drug companies "to reveal operational costs in order to better understand pricing for ultra-high-priced drugs," his office said in a news release. These pieces of legislation should be approved.
So while Kaiser deserves praise for doing the right thing in this case, a bigger problem of increasing prescription medication costs persists.