This post originally appeared in the Daily Memphian on February 27, 2019.
As we trudge through February’s chill, rain and the ever-present potholes, I can’t help but look forward to the start of baseball season and those summer days having a cold beer while cheering my favorite team. Baseball is unpredictable. A stolen base, a wild pitch or a ninth-inning home run can change the course of the game. Epilepsy, like baseball, is unpredictable. Heat, humidity and exposure to the sun can trigger a seizure, and that’s what happened to a friend of mine who accompanied me to a game last season. The unpredictable nature of the disorder often makes epilepsy difficult to control and manage.
Epilepsy treatment requires an examination and often special testing with a neurologist and/or epileptologist to determine what treatment is best for each individual patient. Medicare recognizes the difficulties in treating refractory (uncontrolled) epilepsy. As a result, Medicare Part D plans cover “all or substantially all” anticonvulsants – one of six “protected classes” of drugs that are vital to treating epileptic seizures.
However, the Centers for Medicare and Medicaid Services (CMS) proposed to scale back the six-protected-classes policy, a proposal that would limit access to life-saving medications and put the health and well-being of epilepsy patients at risk.
Under the current policy, protected classes ensure that our country’s most vulnerable Medicare patients have access to the medications they need. Not only has CMS proposed to scale back this policy, the agency also proposed giving insurers more flexibility in limiting coverage for the drugs in these protected categories through requirements like prior authorization and step therapy. These requirements, while well intentioned, often delay or prevent access to vital drugs. In addition to treating epileptic seizures, medications in these protected classes treat patients with cancer, HIV, mental illnesses, and those in need of organ transplants.
Patients who rely on anticonvulsants should not have their treatment plans compromised to justify cost savings. Epileptic patients must have access to the medications and treatments prescribed by their doctors. Changes to the six-protected-classes policy may well exclude certain drugs from coverage and lead to interruptions in treatment, destabilizing patient conditions.
Neurologists and epileptologists need the discretion to choose the anticonvulsant drugs most likely to successfully control seizures. Patients who are not seizure-free are at increased risk of sudden unexpected death in epilepsy (SUDEP), intellectual disabilities, poor developmental outcome, and other chronic diseases such as depression. Moreover, decreased access to effective treatment is associated with poor quality of life because of the side effects of ineffective medications, associated symptoms and loss of independence.
The cost of health care today is far too high. However, decreasing access to effective medication through Medicare Part D’s protected classes policy in the name of frugality is unconscionable. We can and we must find a better solution.
Elisa Hertzan is the executive director of the Epilepsy Foundation of Middle and West Tennessee. Before joining the foundation in 2017, she practiced law for more than 25 years in Tennessee, New York and New Jersey.