New National Initiative Established to Advocate for Doctor-Patient
Led Decisions vs. Harmful “Step Therapy” Interventions
WASHINGTON–(BUSINESS WIRE)–Most of the nation’s top health insurers and PBMs receive a failing
grade in providing access to medicines at the pharmacy counter for
patients with autoimmune disease, according to a new report card from
Let My Doctors Decide. The analysis, based on research from Dr. Kenneth
E. Thorpe and Manasvini Singh of Emory University, highlights the extent
to which private and Medicare health plans utilize coverage limitations
on medications for five of the most serious autoimmune diseases: Crohn’s
disease, multiple sclerosis, psoriasis, psoriatic arthritis and
rheumatoid arthritis. The coverage limitations evaluated include prior
authorization, formulary status, tier placement and step therapy – a
practice whereby insurance companies mandate that patients, many of whom
are seriously ill, try a series of drugs before covering the cost of
doctor-recommended medicines.
The report card was released in conjunction with a new initiative, Let
My Doctors Decide, which will focus on three core areas: 1) educating
patients and doctors about step therapy 2) proposing solutions to
prevent step therapy and other harmful practices from being used by
health insurers and PBMs and 3) providing tools and resources to help
patients overcome these access challenges.
As policymakers in Washington consider proposals that would expand the
use of step therapy within Medicare Part D’s “six protected classes” and
Medicare Part B, the report card released today demonstrates how the
vast majority of private and Medicare health plans, including AARP
Medicare Rx Preferred, Humana Walmart Rx Plan, Blue Cross Blue Shield
Federal Employee Plan Standard and others, impose significant to severe
restrictions on access to the most appropriate medicines for the
diseases evaluated in the study. According to the findings, 86% of
Medicare Advantage and Part D plans received an “F” for access to
medicines at the pharmacy. All plans within Medicare Advantage and Part
B received an “A” for access to medicines that are administered in a
doctor’s office.
The five autoimmune diseases studied do not fall within Medicare Part
D’s “six protected classes,” however, the findings show how coverage for
drugs within these therapeutic classes may changes if reforms are
enacted. Patients who need medicines that fall within the “six protected
classes” may see higher access restriction (similar to Part D).
Furthermore, the “A” grade that Part B plans received would be
jeopardized if step therapy were expanded and physician-administered
drugs were treated more like Part D – as outlined in one of the
Administration’s proposals.
“We are bringing critical attention to step therapy and other
restrictive practices that undermine the doctor-patient relationship and
give insurance companies the ability to make treatment decisions,” said
Randall Rutta, Chair of the Advisory Task Force, Let My Doctors Decide.
“When recommended by doctors for medical reasons, step therapy can be
the right choice. However, there is an important distinction between
sound medical protocol versus economically-driven decisions that do not
take into consideration what is medically best for the patient.”
Let My Doctors Decide is driven by an advisory task force of patient
advocacy and provider groups led by the American Autoimmune Related
Diseases Association. The expanded task force includes the American
Behcet’s Disease Association, American Gastroenterological Association,
Coalition of State Rheumatology Organizations, Dermatology Nurses’
Association, International Foundation for Autoimmune and
Autoinflammatory Arthritis, Lupus Foundation of America, National
Organization of Rheumatology Managers and Sjögren’s Syndrome Foundation.
To read the full results of the report card and learn more about this
new initiative, visit www.letmydoctorsdecide.org.
About Let My Doctors Decide
Let My Doctors Decide is a national partnership of leaders across health
care working in support of a simple goal: treatment decisions should
always be made by patients and trusted health care professionals, not
insurance companies or pharmacy benefit managers. To learn more, visit www.letmydoctorsdecide.org.
Advisory Task Force Members Comment on Today’s
Announcement
“This report card clearly illustrates the critical importance of
ensuring that doctors and patients are able to make treatment decisions.
Calling national attention to this unfortunate situation is desperately
needed, and AARDA and its partners are committed to severely limiting
step therapy and other access restrictions imposed by insurers and
PBMs.” – Virginia Ladd, President and Executive Director, American
Autoimmune Related Diseases Association
“We strongly support this effort to raise awareness about the harmful
consequences that step therapy practices create, specifically the
preventable delay of patient access to medicines. It is time for health
insurers to leave treatment decisions where they belong – in the hands
of trusted medical professionals.” – Mirta Santos, MD, Executive
Director, American Behcet’s Disease Association
“Regardless of one’s medical condition, patients should be able to
easily receive the medicines that their health care provider has
prescribed to them. Step therapy is not an acceptable practice.
Requiring patients to cycle through different treatments can take time
and delay access to the right treatment. These delays can ultimately
lead to disease progression and even put patients at risk.” – David A.
Lieberman, MD, AGAF, President, American Gastroenterological Association
“We applaud this effort and look forward to working with all of the
partners of Let My Doctors Decide to help educate individuals about the
pitfalls and medical risks associated with step therapy. The serious
medical and economic ramifications resulting from short-sighted step
therapy practices, particularly in an autoimmune patient, far outweigh
any perceived short-term savings.” – Madelaine Feldman, MD, FACR,
President, Coalition of State Rheumatology Organizations
“As nurses on the frontlines of patient care, we see the negative
implications of step therapy, as well as the serious consequences of
denying access to the proper medicines in a timely fashion. We are
looking forward to working with all of the partners of Let My Doctors
Decide to help patients navigate this harmful practice.” – Jane Glaze,
BSN, RN, DNC, President, Dermatology Nurses’ Association
“Step therapy does not work for all patients – it is usually only
conducive when treating individuals who meet general patient population
standards. Let My Doctors Decide is helping to raise awareness about
ineffective access restrictions, and we are pleased to support this
important effort.” – Tiffany Westrich-Robertson, CEO and Co-Founder,
International Foundation for Autoimmune and Autoinflammatory Arthritis
“This national initiative is necessary to raise awareness about the
significant consequences associated with step therapy. People living
with lupus take an average of eight medications and it’s critical that
they and their doctors have the final say on what treatments are most
appropriate for their specific medical needs. Let My Doctors Decide will
go a long way in educating the public about the impact of step therapy,
which too often jeopardizes patient health.” – Stevan Gibson, President
and CEO, Lupus Foundation of America
“Why are insurance companies and pharmacy benefit managers allowed to
override the medical recommendations of trusted healthcare
professionals? This is unacceptable, and work driven by Let My Doctors
Decide and its partners is critical in stemming the tide of this
misguided practice.” – Andrea Zlatkus, Board President, National
Organization of Rheumatology Managers
“When it comes to a condition like Sjögren’s, it’s particularly
important to have doctors and patients making decisions involving
medical treatments. The Foundation looks forward to working with Let My
Doctors Decide and its partners on this critical initiative.” – Steven
Taylor, CEO, Sjögren’s Syndrome Foundation
Contacts
Media Contact:
Laura Simpson
[email protected]
(586)
776-3900
