Debarrin Norman is 15 years old and loves basketball. He plays every day. But over the past two years, his mom, Toya Lacey, has seen him more and more often on the sidelines, wheezing and gasping for air. His current medication is just not doing the trick, she says.
Those two years have coincided with three changes to his asthma medications, all dictated by Medicaid and United Healthcare, the managed care organization in which Lacey enrolled Debarrin when they signed up for Medicaid. The changes were unrelated to Debarrin’s symptoms or his doctor’s advice.
“Some medications are made by multiple manufacturers, and products are often interchangeable. In those cases, [managed care organizations] may change their product preferences depending on which is more cost-effective,” said Ali Fogarty, communications director for the Pennsylvania Department of Human Services, which oversees Medicaid in Debarrin and Lacey’s state.
Debarrin’s mom said, “he’ll just play it out and then go sit down, and then you see him on the sidelines just trying to gasp for air, coughing, taking his medicine.”
Two years ago, Debarrin was on Advair, a daily asthma medication intended to control symptoms and prevent flares. Lacey says he was doing well on it.
When Lacey stopped working to care for her 7-year-old daughter with autism, she lost her commercial insurance and enrolled in Medicaid, which did not cover Advair.
Since then, Debarrin has been on three other medications for his asthma: Flovent, Dulera and Airduo. All are daily inhaled steroids meant to control the symptoms of asthma but have different active ingredients, different doses and different modes of delivery than Advair.
The changes have been dictated by his insurance, his mom says, not by his physicians or symptoms. Each time, Lacey says, she has received a letter from United Healthcare long after the change was made and the doctor had switched the prescription in response.
Lacey considers herself fortunate that, each time she’s taken Debarrin in for a doctor’s visit, the physicians have checked whether his medications are still covered. She could have otherwise found herself paying high out-of-pocket prices at the pharmacy or calling the office to ask that his prescription be switched.
Insurers, both private and public, use this tactic, known as non-medical formulary switching, to limit the coverage of prescription drugs to the medications for which they can negotiate a lower price. What that means for patients is that at any given time, their insurance provider may stop covering the medication they take and ask them to take a similar one instead.
“There are instances when difficult decisions have to be made due to formularies, but in general, [medication switching] is not this thing that is done on purpose just to save a couple of bucks here and there,” said Daniel Nam, executive director of federal programs at America’s Health Insurance Plans, the largest advocacy organization for health insurance providers nationwide.
“We work with what we are given. If we are given a bad hand by Pharma … there is only so much we can do,” he added.
Nam suggests that improvement efforts be aimed at identifying areas where medication switching is having unintended consequences, as is the case for Debarrin and others like him with asthma.
“We’ve been dealing with changing his medications over and over and over again for insurance purposes,” Lacey said. “Why does everybody think they can just change my son’s medicine so haphazardly? They don’t know how it affects him. They don’t know what type of asthma he has, what his issues are. They don’t know his triggers, and they don’t know how many times I’ve had to change his medicine.”
In the case of children with asthma who require daily medication to bring down the inflammation in their lungs, medication switching can lead to delays in treatment that put them at risk for an asthma flare, which could in turn land them in the emergency room, explained Dr. Tyra Bryant-Stephens, professor of pediatrics at The Children’s Hospital of Philadelphia and director of the Community Asthma Prevention Program. She is not involved in Debarrin’s care.
The search for cost-effectiveness on the part of insurers may indeed be at the heart of the issue.
The practice has left Lacey wondering, “if the doctor wants me to have the one that’s not covered, shouldn’t that be the medicine that he should be taking?”
She says she has not reached out to United Healthcare with this question due to long call wait times and receiving what she says was incorrect information to prior, unrelated questions.
United Healthcare said in a email to CNN, “we are committed to working with the people we serve and their physicians to ensure that their needs are met with clinically-appropriate therapies.”
Lacey is not alone in questioning the practice; some physicians do, too.
“In general, that’s not a bad idea: to keep health care costs down. The issue is when these changes are made frequently and made for nonclinical reasons,” Bryant-Stephens said.
She and her colleagues who care for children with asthma explain in a recent policy brief that frequent medication switching poses a threat to children in several ways.
Children and teens who are doing well and responding to their therapy are forced to use unfamiliar medications. These medications may not have the same dosing, delivery systems, side effects or efficacy, as Debarrin has experienced.
Children with asthma, for whom following prescribed regimens is already a challenge, may find additional barriers to taking their medication when the frequency, dose and mode of delivery are changed, the brief explains.
Then, there’s the communication gap: Bryant-Stephens says she does not always know when coverage for a particular medication has changed, and she often can’t keep track. There can also be a window of time in which children are not getting the medication they need.
“Parents who are living really stressful lives can’t stop what they’re doing to take care of that one item, necessarily,” she said. “So if you have a child who seems to be OK, doesn’t have symptoms right then, you may delay that just because of all the other competing priorities.”
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The medication switching may also not be cost-effective. In a recent review of the issue, researchers found the practice does not save health care dollars in 90% of instances.
“I don’t understand the business side of it,” Lacey said. “But what I do understand is that there are children who are taking asthma medicine because they need to breathe.”
Lacey took her son to his pediatrician last week.
“I was scared. … I was concerned yet again when I went in, we’re gonna be on medication No. 5,” she said.
“I’m OK for right now,” she said. But she constantly wonders how long it will be until the current deal expires and Debarrin’s medications are changed again.