Florida health plans reject nearly 50 percent of claims for treatment
WASHINGTON – On Saturday, August 5, the Partnership to Advance Cardiovascular Health will host a health forum, “Advancing Cardiovascular Health & Patient Access to Innovative Therapies.” The lunchtime event in Orlando at the Florida Medical Association’s annual meeting will bring together patient advocates, clinicians, and policymakers to discuss innovations in cardiovascular therapies, high rates of cardiovascular disease in Florida and barriers that patients face in accessing new cholesterol-lowering drugs. Seth Baum, MD, founder of Excel Medical Clinical Trials and president of the American Society for Preventive Cardiology, will lead the forum.
STATEMENT FROM SETH BAUM, MD, BOCA RATON CARDIOLOGIST/LIPIDOLOGIST AND PRESIDENT OF THE AMERICAN SOCIETY FOR PREVENTIVE CARDIOLOGY:
“As a physician, there is nothing more frustrating than working with a patient to make a diagnosis and recommend a course of treatment, only to have that treatment denied by unreasonable outside forces. Trust between a patient and physician is sacrosanct and must be protected. We have new, groundbreaking, highly effective medications that can lower cholesterol and reduce the risk of heart attack and stroke, yet Florida insurers’ rates of rejection for these potentially life-saving medications is alarming. Working together we must find a solution that ensures patients have access to the medicines their physicians prescribe.”
In a February Florida Health Plan Coverage Report Card from the Institute for Patient Access, data shows Florida health plans reject nearly 50 percent of claims for breakthrough cholesterol-lowering medicines known as PCSK9 inhibitors.
PCSK9 inhibitors work by extending the lifespan of a receptor on the liver that clears LDL, or “bad” cholesterol. Patients, some with a genetic condition called familial hypercholesterolemia, or FH, are at increased risk for cardiac events such as heart attack and stroke because of extremely high levels of LDL. Clinical trials data show that PCSK9 inhibitors can lower LDL cholesterol more than statins alone and can also reduce the associated risks of heart attack and stroke.
The Florida Health Plan Coverage Report Card data, collected from August 2015 to July 2016, reflects PCSK9 inhibitor claims for Florida managed care organizations, including commercial plans, Medicare and managed Medicaid.
Key Florida Findings:
· 45% average rejection rate
· 3,784 total rejections
· 1,197 appeals
· Highest rates of rejection: Federal Employee Benefit Plan (77%), Express Scripts (76%), Cigna Healthcare (63%)
· Lowest rates of rejection: Aetna US Healthcare (29%), Freedom Health FL (29%), Humana Health Plan (29%)
The least patient-friendly plans were the Federal Employee Benefit Plan, with a rejection rate of 77%, and Express Scripts at 76%. Also denying claims at a far higher rate than the state average were Cigna Healthcare, 63%, and Florida Blue, 61%. Humana Health Plan, Aetna and Freedom Health Florida denied fewer than 30% of claims.
The Partnership to Advance Cardiovascular Health launched a national change.org petition in June to the National Association of Insurance Commissioners to raise awareness about the alarming rejection rates that qualifying patients face across the country. To date, the petition has garnered nearly 3,000 signatures.
Saturday, August 5
Noon – 1:30 p.m.
Loews Sapphire Falls at Universal Orlando
Room: Grand Caribbean 3
6601 Adventure Way
Orlando, FL
The event is open to the press. Press interested in attending should RSVP to Susan Hepworth at shepworth@allianceforpatientaccess.org no later than Friday, August 4.
Resources
Partnership to Advance Cardiovascular Health http://www.advancecardiohealth.org
###