Andrea Zlatkus, CMPM, CRMS, CRHC, executive director, National Organization of Rheumatology Management (NORM), offers insight into the unique challenges high deductible health plans present for rheumatology patients and shares what she wished payers better understood about managing this patient population.

Thank you for speaking with us today. Can you please introduce yourself and tell me a bit about your background?

My name is Andrea Zlatkus. I have been a rheumatology practice manager for the last 25 years at Chester County Rheumatology in Westchester, PA. However, this year, I have been named the NORM Executive Director so I am in transition and that is going to be my full time job and I am going to be part time with the practice itself. During my time as a practice manager, I spent a lot of time helping patients making decisions with health insurance, which is kind of what we are going to be talking about today, so I’ve seen their challenges and their frustrations.

Can you comment on some of the challenges and rheumatology regarding high deductible health plans for patients?

I am really acquainted with these because I've had a health a high deductible health plan, myself, for the last 10 years or so. Not only do I know about all my patients have to go through, but what I have gone through myself, personally.

Many of our patients do take advantage of the high deductible health plans who are using biologics and our infusions suite, because then they can take advantage of the pharmaceutical rebate programs that help pay for that high deductible biologic costs and it helps wear down their deductible. So for instance, if the patient has a $5000 out-of-pocket pocket expense, the pharmaceutical company picks up everything but that $5 and that push can go towards their deductible. Now, that's how it works on the medical side. However, it is a different story on the pharmacy side. Many of these plans have cost accumulator clauses within their plans that only allows the patients $5 that they pay personally to go towards their deductible. So they never really meet their deductible and these drugs are very expensive and so they pay a lot of out-of-pocket expense for the full deductible and that happens really quickly beginning of the year, so there are some of the challenges with having that high deductible plan.

When I talk to my patients, one of the things I really stress is that, even though they may be on a biologic in my infusion suite, that does not guarantee that that's the first and only time they are going to run into challenges. For instance, if come January 1, they need to go to the emergency room for any reason they may have to pay that whole deductible right to the hospital.  And sometimes they're not expecting it, they just figured, well I'll use my copay card or they’ll have the full year to pay for it. I always tell them they have to make sure that they have the funds. When they don't, this can be financially catastrophic for these patients. All of a sudden, they have this huge deductible due beginning of the year and they are not prepared for it and they don't know how to come up with that money.

What solutions do you recommend for providers trying to navigate these challenges?

Education is the best. Educating the patients on some of the benefits but also some of the negatives of taking those high deductible plans so they can prepare for them. These high deductible plans are recurring, so they’re not just expected to meet the deductibles once in 2021 but, again in 2022 and 2023. It's not a one-time fee so education is key.

We do a lot of education and outreach during open enrollment, which we are in right now — it started October 15^th—so it's a great time to educate our patients. We also have to remember that patients go into Medicare every single day. If somebody is turning 65 and they need to make those decisions or choices. They might have understood where they were in commercial insurance but Medicare and Medicare Advantage plans are a whole new ballgame, so a lot of education is key.

On our NORM website, we share some open enrollment brochures and we update them annually. They are great resource for practices to download and share with their patients. There is one on commercial insurance, another on terms, and one on Medicare/Medicare Advantage plans. They help facilitate that conversation with your patients.

What can payers do to alleviate the burden of some of these processes and improve patient outcomes?

Be open about what their insurance plan covers and what it does not cover. One of the things I try to give my patients is a list of questions. It is not enough to say, “Do you cover my drug?” because the answer is always yes. What they need to follow up with is, “…at what out-of-pocket cost to me?” as the patient.

And many are surprised that, even under Medicare Advantage, some of the biologics have up to $7500 deductible. When they call or they see these great TV ads, they say “It's just like Medicare right?” And it is, because Medicare only pays 80% and that connection is really not made to the patient. Some of these Advantage plans only pay 80% and patients need to know that when they sign up. Also, if there is that $7500 high deductible, patients need to understand that as well, because what happens is patients end up not getting treated at all. They suddenly find that they have this out-of-pocket expense, and they can't afford it. We try to help them through it or tell them you can switch back to straight Medicare. And we've had patients who just stop and say, “I can't do it and I’ll wait until next year,” no matter what we do to convince them that it can be fixed. Once they are hit with that out-of-pocket expense, it is really difficult.

What is something that you wish payers understood better?

I wish they understood that these are chronic diseases. Rheumatology patients are just episodic like in oncology where they have a defined treatment plan. This is year after year, and they can't look at the patient like they are with them for one year and then next year they will be somebody else's problem. It doesn't work this way these patients.

When I started in rheumatology 25 years ago, their hands were so deformed. You can always tell when a patient had rheumatoid arthritis, because of all the deformities they couldn’t do something as simple as button their shirt or open the door knobs—you know, things that we all take for granted. And it was so hard to see these patients go through this, but because of these biological treatments that doesn't happen anymore. I have staff members who never saw patients whose hands were as deformed as I did when is started in rheumatology, which is great, but these patients need to be taken care of now and into the future, so they don't stop getting treated and go back to the days, where they do have these deformities end up in the emergency room, facing further disabilities, so we really need to take care of these patients now.

Is there anything I haven't asked you about or anything that you'd like to add?

I think we just really want to take care of these patients. I think if there are clauses that are put into the plans that are kind of hidden or go by all these different names, it is too confusing for patients. They have to be upfront and honest with the patients. Important coverage information cannot be buried on page 68 of the brochure, right? They need to know what they're signing up for, both the good and the bad, so that they can make the most informed decisions.