By Angus Worthing
September 23, 2019 at 5:00 am ET
Arthritis is one of the most common chronic conditions in the country, affecting more than 54 million adults in the United States. Known for causing widespread joint pain and inflammation throughout the body, the physical side effects are grueling for patients typically between 30 and 60 years of age.
The economic costs that the illness carries are almost as painful. It’s estimated that medical care costs and earnings losses for adults with arthritis were $303.5 billion in recent years. And that number is expected to grow as the number of patients diagnosed with the condition increases.
As a rheumatologist, I’ve witnessed and marveled as science provides patients and society the tools we need to manage this debilitating condition. While there is currently no cure for arthritis, new medicines can reduce pain and prevent progression to disability for people with certain kinds of autoimmune diseases like rheumatoid arthritis. The progress we are making is encouraging, and there’s plenty of reason to hope a cure is on the horizon.
Unfortunately, short-sighted policies in Washington threaten to make matters worse. New rules could allow seniors to be denied the treatment they need when it’s needed.
Physicians know better than most that every patient is different and has a unique story. After thoroughly examining a patient, we work together to determine how we can best manage his or her condition. There is no one-size-fits-all approach, which is why collaboration between the doctor and patient is key in deciding which course of treatment will deliver the best results.
Once a treatment decision has been made, however, the patient is far from the finish line. Insurance companies may require a patient to try and fail on a different medication that provides a larger “kickback” payment to the insurance company and/or intermediary pharmacy benefit manager.
The process, known as step therapy, is all too common in health care today. Patients deserve access to the right medicines when they need them. Delays in care can result in irreversible damage to chronic illness patients, including those with arthritis.
Recently, I treated a young woman with rheumatoid arthritis. Her symptoms were flaring up; she was in a lot of pain, and she was trying to become pregnant. We discussed her options and made a treatment decision based on her specific needs.
After a prescription was sent to the pharmacy, she was denied coverage for the drug and was told she needed to try a different treatment first. If this alternative failed to deliver the desired results, the insurance company would consider other options, including the one that was originally prescribed.
Taking matters into my own hands, I wrote a letter to the patient’s insurance provider. Weeks later, an appeal was reviewed and eventually the treatment was covered, but during that time, this young woman experienced a lot of trouble managing her condition. When I prescribe a medicine for somebody with severe joint pain, it’s because they need the medicine to feel well. These delays caused this woman unnecessary suffering that could have been avoided with a faster appeal time.
That is why patients and physicians have been sounding the alarm over a new Trump administration rule that allows insurers to impose greater use of step therapy on America’s seniors. The rule applies to seniors enrolled in Medicare Advantage plans who need medicines administered in an office or infusion center and those covered by Medicare Part B.
This dramatic departure from long-standing policy came with little warning and few guardrails. It’s been said the rule will inject more competition into the system. But it’s really a way for insurers to manage their costs at the expense of vulnerable patients.
The time doctors spend fighting for patients impacted by step therapy is time that should be spent taking care of other patients. Today there is a workforce shortage in the field of rheumatology. There aren’t enough rheumatologists to take care of this growing patient population. We need to work and care for our patients efficiently, yet step therapy makes the job of physicians even harder.
Fortunately, public officials are starting to recognize the problems with step therapy. Legislation introduced at the state and federal levels will bring reasonable reforms to step therapy, but there is a lot of ground to cover. In a society that promises its citizens incredible, life-changing medicines, it’s heartbreaking when people are denied access to them.
Everyone — doctors, patients and their families — must raise their voice to support legislation to help fulfill that promise so people living with arthritis can get the treatment they deserve.
Dr. Angus B. Worthing is a rheumatologist at Arthritis and Rheumatism Associates, P.C., serving the Washington, D.C., metro area, and he also serves as chairman of the American College of Rheumatology’s Government Affairs Committee.
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