This health insurance provider plans to cut in-clinic asthma treatments from Texas plans

A major health insurer of Texans is set to make significant changes to how some asthma patients receive what doctors say are medically necessary treatments.

Starting April 15, Blue Cross Blue Shield of Texas will stop covering certain asthma infusion treatments in clinics, obliging patients to self-inject the drugs at home.

The provider “will review the medical necessity of administering drugs in a health care setting when they could appropriately be self-administered,” according to a press release. Patients on Medicare and Medicaid will not be affected.

The drugs under review — Fasenra, Tezspire, Nucala and Xolair — are infusion treatments that modify inflammation in the immune system to control asthma symptoms. They are generally administered monthly as maintenance drugs for people with moderate to severe asthma.

The provider will cut this coverage from its plans in Illinois, Montana, New Mexico and Oklahoma, as well, according to the medical industry news site Fierce Healthcare.

Asthma doctors say the move will put their patients at risk of life-threatening reactions when taking the drugs at home. Blue Cross Blue Shield of Texas says the change will make the treatments more convenient and effective, citing the drugs’ approval for self-injection by the Food and Drug Administration.

What effect will the policy change have on asthma patients?

Asthma and allergy doctors say that forcing patients to self-administer these drugs at home could have life-threatening consequences.

These treatments are usually tailored to a patient’s immune system, and this specificity can often lead to adverse reactions, according to Dr. Amin Mery of Hill County Allergy and Asthma in Austin.

“Those reactions can be potentially severe and even life-threatening,” Mery said in an interview. “We can manage those in the office, but it’s very difficult for them to manage them at home.”

There is also the possibility for patients to administer an incorrect dosage, he said, and many tend to stop taking their medications as a result.

A spokesperson for Blue Cross Blue Shield of Texas highlighted that all of the drugs in the policy change have been FDA approved for self-injection.

“Our policy revision is being made with the interests of our members in mind — promoting access to treatment that is convenient and effective,” the spokesperson said.

Asked if the revision would end up costing policyholders more or less out of pocket than the current policy, the spokesperson said it “depends on the plan that the member selected.”

The FDA has indeed approved these drugs for self-administration. But all of their labels also warn of the severe allergic reaction known as anaphylaxis as a possible side effect. The label for Xolair includes FDA’s most serious safety notice known as a “boxed warning.”

Xolair has been found to cause anaphylaxis both upon the first dose as well as over a year after treatment has begun, the label warns.

The manufacturer states that anaphylaxis has been found to occur in just 0.1% of patients.

Over-the-counter pain medications like aspirin have also been found to cause anaphylaxis, according to the Mayo Clinic.

Still, doctors say anaphylaxis is a serious reaction that can be managed more safely in a clinical setting than in the home.

The policy change includes an exception for policyholders for whom it is medically necessary that they continue receiving the treatments in clinic. A policyholder would have to show that continuing in-clinic injections adheres to “generally accepted standards of medical practice,” according to the provider’s definition of “medically necessary.”

In order to take advantage of this exception, patients have to go through an onerous appeals process, according to Brad Traverse, executive director of industry advocacy group Infusion Providers Alliance.

“And if you’ve ever been on the business end of a health insurance appeal, it’s horrible,” he said in an interview. “And why should you have to? You’re basically second-guessing the doctor. The doctor knows where and when these drugs should be administered.”

How many Texans will be affected by the policy change?

Blue Cross Blue Shield of Texas covers over 10.4 million people in the state. A company spokesperson did not provide numbers of how many of those policyholders receive treatment for asthma.

Over 2 million Texans have asthma, according to the most recent data from the state Health and Human Services Department. Nearly a quarter of those — more than 492,000 — are children. That puts the statewide child asthma rate at 7%.

But here in Tarrant County, children suffer from asthma at more than three times that rate, according to a 2012 study of the links between asthma and social problems like school absenteeism and low academic performance by researchers at UT Arlington.

“The prevalence of asthma in school-aged children in the target area is 19% to 25%, which exceeds both national and state values,” the study determined.

At the low end of that scale were 6-year-olds and at the high end were 9-year-olds, while 23.5% of 12-year-olds and 20.6% of 15-year-olds had asthma.

The study focused on Tarrant County and others comprising the western half of the Metroplex due to poor air quality, rapid development, high concentrations of natural allergens and the area’s state-leading natural gas production.

Dr. James Haden of the Allergy and Asthma Clinic of Fort Worth said he administers 20 to 25 of these medications a day in his office. He wrote a letter to Blue Cross Blue Shield of Texas in February to express his opposition to the change.

The policy change will “significantly compromise patient safety, limit treatment options, increase administrative burdens, and ultimately drive up healthcare costs,” he wrote.

Mandating at-home administration of these medications “takes away the choice of the patient and the physician as to what might be the best for each individual patient,” he said in an interview.

“Everything is tailored to try to help that person in front of you,” he said. “It’s not cookbook medicine.”

Who will benefit from Blue Cross Blue Shield’s change to asthma treatment coverage?

Blue Cross Blue Shield of Texas said the policy change “promotes access to the treatment via the most convenient and effective benefit for the member,” but doctors and industry advocates aren’t buying it.

Mery, from the Austin asthma clinic, questioned the decision-making process behind the change in coverage, saying he believed it was “not necessarily patient-oriented.”

Traverse, of the Infusion Providers Alliance, had some insight into who has more to gain from the policy change.

“It’s pure and simple cost cutting,” he said in an interview. “There’s no question that it costs them less to have these treatments done at home.”

Under the current coverage of these treatments, drug companies ship these drugs directly to clinics, but Traverse said the change will not only save the provider money, but it will also open a new revenue stream.

Blue Cross Blue Shield’s parent company, Health Care Service Corp., has circuitous financial ties to specialty pharmacy Accredo, which Traverse says will distribute the drugs.

“When physicians administer these injections, HCSC doesn’t profit,” Traverse said in an email exchange. “But when patients are forced to inject themselves, the insurer can steer them to Accredo, a specialty pharmacy with financial ties to HCSC — allowing the company to pocket a cut.”

Accredo is owned by Express Scripts, a pharmacy benefits manager that is not owned by Blue Cross Blue Shield or HCSC. Prime Therapeutics, which is partially owned by HCSC, uses Express Scripts’ retail pharmacy network, which includes Accredo.

The spokesperson for Blue Cross Blue Shield of Texas said “there are not any revenue streams that lead from Accredo to BCBS/HCSC through the sale of these drugs.”

Traverse had his doubts.

“The supply chain is complex,” he said. “I can’t show where the dollars go, but they have that contractual relationship. … I’m sure they could find a way to say, ‘No, we don’t have a direct benefit,’ but it’s a contractual relationship. You don’t do contracts unless you’re going to make a profit from it.”

Meanwhile, doctors say their patients will bear the brunt of the negative effects resulting from the policy change.

“The thing that scares me the most is taking away choice from the patient and taking out the expertise of the physician and making decisions collaboratively that are in the best interest of the patient,” said Haden, the Fort Worth allergy doctor. “It’s medicine by dictation, instead of by consensus.”

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