Jessica Daitch
Phone: 917-816-6712
Email: [email protected]

Survey Finds Insurance Companies are Forcing Massachusetts Patients Off Prescribed Medications During the Plan Year, Providing A Need for New Legislation to Fix the Problem

Nearly all respondents (94%) support legislation prohibiting insurance companies from financially pressuring them to switch from their prescribed medication

UPPER NYACK, NY (December 11, 2017) – A coalition of 19 patient and provider organizations known as the Massachusetts Patient Access and Safety Coalition today released results of a survey showing that a majority of those in Massachusetts living with chronic health conditions have experienced “non-medical switching”—insurance coverage reductions which pressure patients to switch their prescription medications. Reductions in coverage include increased out-of-pocket costs, eliminating a drug from the formulary entirely or other restrictions around access. The survey, which was conducted by the Global Healthy Living Foundation (GHLF), found that consumers are being hurt by insurer and pharmacy benefit manager (PBM) initiated switches and support state-level action on the issue. Already, Massachusetts state officials are listening to consumer and provider advocacy organizations to determine legislative action options regarding non-medical switching. Related legislation is expected to be proposed in a minimum of eight states in 2017.
In many cases, the alternative therapies that the patients are being pressured by pharmacy benefit managers to switch to are made by manufacturers that have successfully produced lower bids than the existing preferred drug from a different manufacturer on the insurance plan. The Massachusetts Patient Access and Safety Coalition suspect a switch is typically beneficial only to the pharmacy benefit manager (PBM) and the insurance company. The coalition has been unable to determine benefits of a switch, like cost savings, are passed on to the patient in lower premiums, deductibles, or coinsurance/copays
“This is the last week of the 2018 federal Health Insurance Marketplace open enrollment period (ending December 15) and December is typically the time that many employer-offered plans will ask their employees to re-select their plan for the new year. The contract that Massachusetts residents will sign is very specific, but what they may not realize is that their insurer is allowed to alter the contract by reducing their drug coverage at any time during the plan year,” stated Seth Ginsberg, president and co-founder of GHLF, whose mission is to improve the quality of life for people with chronic illness and is a member of the Massachusetts Patient Access and Safety Coalition. “Not only is the contract unfair to consumers, but it puts patients’ health at risk when access to their medication becomes uncertain. It’s time for legislators to protect patients from non-medical switching.”
While consumer fairness is a main concern, patients and providers argue non-medical switching is harmful to patient health and undermines providers’ efforts to do what’s best for their patients. The survey found that nearly two-thirds (64%) of Massachusetts residents with chronic illness had to switch to a different mediation than what was prescribed due to a change in coverage. Further, nearly 3 out of 4 patients (73%) experienced changes in coverage that caused their primary therapy to become suddenly and significantly more expensive. The majority of respondents (66%) reported now paying more out-of-pocket for their prescribed medication, with 53% reporting to pay a lot more.

Medication Switching Disrupts Care and Leads to Negative Health Consequences

  • 48% of respondents had to try multiple medications before finding another medication that worked for them.
  • 70% reported that their new medication, after being switched, worked somewhat or much worse than the original prescribed medication
  • 61% experienced side effects after switching to a new medication
  • 86% of those who experienced side effects reported that they were worse compared to previous side effects
  • 46% reported seeing their healthcare provider or going to the emergency room due to complications following a switch to a new medication and 18% reported being hospitalized.

“Chronic disease patients, like me, must commit to spending a lifetime managing their disease and it can often takes weeks, months or years to land on an effective treatment strategy. I’ve tried more anti-seizure medicines, in various combinations, than I can name or remember,” stated Carlton Zeigler, a Quincy, MA resident with epilepsy who is a volunteer patient advocate with Epilepsy Foundation New England, another member of the Massachusetts Patient Access and Safety Coalition.

Zeigler said, “It is unethical for insurance companies to interrupt and potentially destabilize a patient’s therapy when they make it more difficult or impossible for that patient to access or afford the medications they prefer and that are prescribed by their physician. Once after picking up my medications from the pharmacy, I discovered that the pills had changed colors and shape. I called the pharmacy and learned that I had been switched to a generic as required by my insurance provider, but should have “no concerns” regarding the switch. Later, I would take my morning dose, but I never saw the afternoon because I awoke in the hospital where I stayed for four days. It may not always be possible to avoid a drug switch, but notification is vital. Drug costs may decline in the short term, but overall healthcare costs will rise as studies show that medication switching increases doctor visits, trips to the emergency room and hospitalization.”

Beyond the health and cost implications, the survey found close to half (42%) of all respondents reported never receiving notifications from their insurer (letters, emails or phone calls) detailing their plan’s midyear formulary changes or modifications being made to their health plan coverage. A majority of respondents (68%), instead, was informed by their pharmacist, and a small percentage (5%) was informed by their physician.

The coalition advocating to reduce non-medical switching by commercial health plans in Massachusetts includes GHLF, AIDS Action Committee, American Autoimmune Related Diseases Association, American Diabetes Association, American Kidney Fund, American Liver Foundation, Arthritis Foundation Massachusetts, Asthma and Allergy Network, Disability Law Center, Epilepsy Foundation New England, Jett Foundation, MA Association for Mental Health, National Eczema Association, National MD Society of Greater New England, National Psoriasis Foundation, New England Hemophilia Association, NORD, PH Association, and U.S. Pain Foundation.

An executive summary and infographic detailing additional survey results is available on the GHLF website at The Massachusetts Patient Access and Safety Coalition plans to continue its outreach efforts to educate patients, providers and lawmakers on the harmful impact of non-medical switching.

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About the Survey

In August 2017, GHLF partnered with the Massachusetts Patient Access and Safety Coalition, which represents hundreds of thousands of Massachusetts residents living with chronic illness and their care providers. GHLF and the Coalition invited Massachusetts residents living with a chronic or rare illness to complete an online, 31-item survey that investigated patient experiences with the manipulation of their respective health plans’ formularies. To complete the survey, eligible respondents had to be residing in Massachusetts and diagnosed by a provider with a chronic or rare disease.

A diverse sample of 143 Massachusetts residents diagnosed with chronic or rare diseases completed the survey (of 260 that started the survey). Although respondents’ individual diseases varied widely, five separate classes were represented: mental health (35%), autoimmune (34%), neurological (29%), oncological (6%), and infectious (1%). Private insurance was held by the most number of respondents (43%), followed by public insurance (36%), and then a combination of private and public insurance (16%). There was an equal percentage (46%) of participants who were employed, either full-time, part-time, or self-employed, as there were participants who were unemployed. The majority of participants (64%) reported having a household income of $50,000 or less per year.

What is Non-Medical Switching?

Non-medical switching occurs when changes are made to a health plan’s formulary (the official list of available and approved medications) in a way that monetarily pressures patients to cease filling their prescribed medication in lieu of a “preferred” or cheaper drug. Insurers are free to change their formulary at will and often do so mid-plan year. Patients, however, cannot renegotiate their contracts until the end of their plan year. Essentially, patients are not being provided with the benefits that were marketed to them during the open enrollment period.

Non-medical switching can be very harmful to patients. As a result of being switched from their original, provider-prescribed medication, patients may experience additional side effects, symptoms, disease progression, and even relapse. Beyond the immeasurable impact of this unnecessary suffering, the negative effects of non-medical switching can result in additional medical appointments, emergency room visits and even hospitalization, thereby actually increasing overall healthcare utilization costs.

About Global Healthy Living Foundation

The Global Healthy Living Foundation is a 501(c)(3) non-profit organization whose mission is to improve the quality of life for people living with chronic illnesses, such as arthritis, osteoporosis, migraine, diabetes, psoriasis, cardiovascular disease and chronic pain, by advocating for improved access to care at the community, state, and federal levels, and amplifying education and awareness efforts within its social media framework. GHLF is also a staunch advocate for vaccines. The Global Healthy Living Foundation is the parent organization of CreakyJoints, the go-to source for more than 100,000 arthritis patients and their families world-wide who are seeking education, support, advocacy and patient-centered research and ArthritisPower, the first ever patient-led, patient-centered research registry for arthritis, bone, and inflammatory skin conditions.