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Report Card Finds Top Health Insurers and PBMs Impose Significant Restrictions on Patients with Autoimmune Disease

WASHINGTON--(BUSINESS WIRE)--

New National Initiative Established to Advocate for Doctor-Patient Led Decisions vs. Harmful “Step Therapy” Interventions

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

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