Cathy Cheatham has taken the drug infliximab to control her arthritis inflammation and joint pain since 2005, sitting through injections for up to three hours at a time with a patience borne of experience.
It’s allowed Cheatham, an accountant who manages charitable bar gambling on the side, to live an active life, juggle multiple jobs and keep up with workers half her age.
“I’m 62 years old,” said Cheatham, of Osseo. “I hate to say it, but for 62, with arthritis, I look good. I’ve had Remicade infusions every eight weeks for 15 years.”
During open enrollment last winter, HealthPartners listed the injection drug on a menu of medications that the Bloomington-based health insurance company would cover in part or in full.
Just weeks later, after enrollment had closed, Cheatham and other patients were dismayed to learn that HealthPartners had dropped the drug from its coverage plans and replaced it with a cheaper alternative.
Infliximab, sold under the brand name Remicade, is an immuno-suppressive injection popular with patients who suffer from Crohn’s disease, an inflammatory bowel disease, or rheumatoid arthritis, a chronic inflammatory disorder that affects joints and can even impact eyes, skin and lungs.
HealthPartners informed its infliximab users in late February that it would no longer cover the drug as of April 1, which struck patients as short notice.
For Cheatham, the timing was especially eye-popping, given that so little was known at the time about COVID-19. Hospitals in March and April were turning away patients to free up resources and reduce the prospect of contagion during the pandemic.
The switch to the bio-similar drug infliximab-dyyb (sold as Inflectra) was so abrupt, in fact, consumer advocates at the time cautioned in letters to the insurer that the changes could violate state and federal law. Outside of open enrollment periods, patients cannot easily switch insurers if benefits change.
LIMITED NOTICE
While HealthPartners sent a notice to medical providers informing them of the change in January, it did not send the same notice to all enrollees until Feb. 20, little more than a month before the switch to Inflectra. The notice also contained a typo incorrectly indicating the change would not happen until 2021.
Under the federal Patient Protection and Affordable Care Act (ACA), health plans must provide a minimum of 60 days notice prior to making any “material modifications,” including benefit reductions.
In a written statement, HealthPartners spokesman David Martinson said because “health and well-being is never one-size-fits-all,” the insurer worked with medical experts to determine when continued use of Remicade would be appropriate.
Medicare Part D members were not impacted by the change in drug policy, he said.
“As drug prices continue to rise, we are constantly looking for opportunities that ensure our members have the most effective, affordable medications and therapies,” he wrote. “Biosimilar drugs are approved by the Food and Drug Administration (FDA) and are as safe and effective as the original biologic drug, and often significantly less expensive.”
In 2018, a study published in the Journal of the American Medical Association found that Inflectra had lower costs than Remicade over an eight-week prescription period ($2,185 compared to $2,667), or annually ($14,202 versus $17,335).
NON-MEDICAL SWITCHING DRAWS SCRUTINY
The practice of “non-medical switching” — or moving subscribers to a different drug for non-medical reasons, usually cost savings — has drawn increased scrutiny from consumer groups and physicians.
Critics note that two drugs that accomplish the same medical goals can have different side effects, and some studies have chronicled an uptick in hospitalizations after a switch, as well as patients suffering depression or abandoning medication altogether.
In March, the nonprofit consumer advocacy organization Aimed Alliance authored a letter of concern to HealthPartners’ co-medical directors, Steve Connelly and Brian Rank.
(Janssen, a Johnson and Johnson pharmaceutical company and maker of Remicade, is an Aimed Alliance funder. An Aimed Alliance spokesman said the advocacy organization has internal “firewalls similar to other … nonprofits” to ensure that its funders have no say over policy priorities and activities.)
The letter, signed by 30 doctors, patients and patient advocates, noted that non-medical switching may violate Minnesota’s consumer protection laws, which expressly prohibit “advertis(ing) goods or services with intent not to sell them as advertised.”
“Given that the switch is scheduled to happen four months after the plan year has begun, plan enrollees could argue that HealthPartners is engaging in unfair and deceptive trade practices,” reads the letter.
They noted that patients with chronic conditions such as rheumatoid arthritis sometimes try a number of medications before they find a drug that works well with their physical system.
Moving a stable user to a new drug can have unforeseen consequences, from uncomfortable side effects to more serious medical reactions, and moving them back and forth is sometimes worse.
HEALTHPARTNERS: REVIEW PROCESS EXISTS
The HealthPartners’ notice to enrollees states that all infliximab use after April 1, 2020 will require a new clinical authorization outlining why the switch to infliximab-dyyb is not medically appropriate.
“We built those circumstances into our review process, ensuring the more expensive drug remains accessible to patients when it’s needed,” Martinson said.
In other words, patients can fight the switch individually, but they need to sway their doctor and go through a formal appeal process hand-in-hand with their medical provider. For specialists who may deal with dozens of infliximab patients at a time, that process would be especially onerous.
Cheatham’s rheumatologist appealed the decision to switch her off infliximab, but HealthPartners initially denied the request. She appealed again and was approved to stay on Remicade through Dec. 31.
