Although one of the aims of the Patient Protection and Affordable Care Act is to get rid of discrimination based on pre-existing conditions, there are still insurers that discourage high-cost patients from enrolling, according to a study released in The New England Journal of Medicine.
The study found that some companies are using "adverse tiering" to dissuade these patients from enrolling, according to researchers at the Harvard T.H. Chan School of Public Health.
For the purposes of the study, researchers described "adverse tiering" as "placement of all nucleoside reverse-transcriptase inhibitors in tiers with a coinsurance or copayment level of at least 30 percent." NRTIs are used in treating HIV.
The researchers analyzed adverse tiering in 12 states using the federal marketplace — Delaware, Florida, Louisiana, Michigan, South Carolina, Utah, Illinois, New Jersey, Ohio, Pennsylvania, Texas and Virginia — and "examined the plans with the lowest, second-lowest, median, and highest premiums on the 'silver' level in each state, analyzing formularies and benefit summaries to assess cost sharing for NRTIs," according to the study.
After looking through 48 PPACA policies from these states, they found evidence of adverse tiering in 12 of the 48 plans.
The researchers said they found "stark" differences in out-of-pocket HIV drug costs between adverse-tiering plans and other plans. Specifically, they said, the average annual cost per drug for people enrolled in adverse-tiering plans was more than three times that of people enrolled in non-adverse-tiering plans ($4,892 vs. $1,615).
Additionally, researchers found that half of adverse-tiering plans had a drug-specific deductible compared to 19 percent of other plans. The researchers estimated that a person with HIV would pay more than $3,000 for treatment each year in an advere-tiering plan than in another plan.
"Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans. A recent analysis of insurance coverage for several other high-cost chronic conditions such as mental illness, cancer, diabetes, and rheumatoid arthritis showed similar evidence of adverse tiering, with 52 percent of marketplace plans requiring at least 30 percent coinsurance for all covered drugs in at least one class.Thus, this phenomenon is apparently not limited to just a few plans or conditions," the researchers wrote.
The researchers concluded that, "The ACA has already made major inroads in designing a more equitable healthcare system for people with chronic conditions, but the struggle is far from over."