Frederica Freyberg:

The assembly amendment that added the co-pay cap may have soothed many in the health insurance industry. Health plan providers who were concerned the bill’s original version would result in passing on higher premiums to plan members. Our next guest is Phil Dougherty, senior executive officer with the Wisconsin Association of Health Plans. Thanks for being here.

Phil Dougherty:

Thank you for inviting me.

Frederica Freyberg:

We know that you were on record as opposing the original version of this bill that passed overwhelmingly in the senate. What’s your reaction to the amendment that got put on it and then passed in the assembly.

Phil Dougherty:

Well, I'd to– Before we get into the bill itself, it’s important to understand a couple of facts. First of all, oral chemotherapy prescription drugs were already covered by all the community-based health plans in Wisconsin, which are our members, and major insurers. So the coverage was already there. Secondly, for many people who have coverage, their benefit plans already provides pretty generous coverage where the co-payments, or co-insurance, that they pay might be considered much smaller than what we were talking about in the legislation, $25, $35 a month.

Frederica Freyberg:

For oral chemo?

Phil Dougherty:

For oral chemotherapy prescription drugs. So that’s already there. I think it’s important to keep that in mind. Oral chemotherapy medications can be very expensive. We heard upwards of $10,000 a month. And there are different benefit designs that both employers, individuals and insurers use to try to keep the cost of health insurance down. Just an example of how this works, the cost of all the medical services that are covered have to be covered by a combination of what is the premium and the amount that individuals pay out of their own pocket. And the more that you move this line between that, the more you increase the premium, you have the opportunity to lower the cost-sharing. The more you increase the cost-sharing, the co-pays, the co-insurance, premiums get lower and is more under control. That's what this debate is all about. So that's the important thing.

Frederica Freyberg:

What was your problem with the original version.

Phil Dougherty:

The problem with Senate Bill 300 is it only affected 29% of the population, first of all. It's not a 100% solution. Only the 29% in health insurers that are regulated by the state are going to be affected by this legislation. Secondly, it doesn’t address the problem of the high cost of oral chemotherapy drugs. That cost still there. And again, what we’re talking about is moving the line, and this bar of cost is expanding all the time. So those are a couple of flaws that we saw. And third, the legislation restricts a tool that employers and insurers use to try to keep insurance premiums affordable. By restricting the amount of cost-sharing, you’re affecting how much can be in the premium. The assembly version of Senate Bill 300, it's a much better bill. What it does is it provides better oral chemotherapy benefit clarity. It’s clear when you have the $100 cap that's stated there. Plus, there’s a little greater financial certainty for enrollees. They understand that they're probably not going to be paying much more than $100 out of their own pocket.

Frederica Freyberg:

And yet health plans have a choice somehow, right, whether to go with the $100 cap or do something else. What’s the something else?

Phil Dougherty:

What the legislation says is, if a patient goes in for intravenous chemotherapy and they pay– They would be required to pay $50 out of their own pocket each time, or per month. The legislation says that insurers can design a benefit plan that matches that. That’s Parody, so $50 for a 30-day supply of the drugs. Or if there is a benefit program that’s out there now, or somebody wants to purchase, where there’s a co-payment of up to $100 for a 30-day supply, that’s deemed to be in compliance.

Frederica Freyberg:

Let me ask you this, what was it like to be on the opposition side of the SB 300 that had such overwhelming support amongst that body in the senate?

Phil Dougherty:

Well, we understand, and health plans understand across the state, that this is a very emotional issue for many people. We heard stories on the legislative floor last night. Stories have been carried in the newspapers. Our member health plans hear those stories all the time. So that’s difficult. But what health plans grapple with is the difference between being able to provide coverage of everything in a very generous way, which is the access part of it, providing access to quality healthcare services, but trying to keep the cost of the insurance affordable, keeping that premium down. Because if the cost goes too high, nobody can afford the coverage anyway. Then everybody’s out of coverage. Fortunately, many of those members, they already have coverage for prescription drugs. It’s a matter of, how large is the out of pocket cost.

Frederica Freyberg:

All right. We need to leave it there. Phil Dougherty, thank you.

Phil Dougherty:

Thank you.