After years of steadily increasing out-of-pocket costs for prescription drugs, American health care consumers are seeing red. And who can blame them? Rising copays — sometimes in the hundreds or thousands of dollars for a month’s supply of a single medication — can stand between a patient and his or her life-saving therapy.
It’s an issue that has reached a fevered pitch, underscored by the recent release of President Donald Trump’s “American Patients First” drug pricing blueprint, which among other proposals, considers transitioning certain Medicare Part B drugs into Part D in an attempt to control drug costs.
But, as Atul Gawande — renowned surgeon and newly tapped chief executive of the Amazon-Berkshire Hathaway-JPMorgan Chase health care venture — recently reminded a gathering of health insurance executives, those infuriating pharmaceutical costs are just 10 percent of overall U.S. health care spending. In our fervor to rightfully attack high drug prices, it’s important that we not miss the forest for the trees with changes that restrict patient access to needed medications.
Yet, according to Avalere Health, a proposal like the one found in Trump’s blueprint could do just that, creating unintended access barriers for Medicare patients who rely on Part B for their drug coverage. Prescribing doctors are similarly concerned that the proposed policy change would subject these patients to a host of utilization management techniques employed by Part D plans — such as high-cost sharing, step therapy, specialty tiering and prior authorization — that too often prevent and delay needed care.
That would be a hard pill to swallow for millions of Americans with autoimmune conditions like rheumatoid arthritis who depend on Part B biologic therapies to avoid the severe pain, swelling, joint deformity and debilitating, life-altering lifestyle restrictions caused by their disease.
It would also be a policy that ultimately hits taxpayers where it hurts most: in the pocketbook. That’s because, even with their high price tags, the biologic therapies covered under Part B to manage chronic disease end up saving the U.S. health care system money by reducing expensive hospitalizations and preventing costly surgeries.
This is a fact policymakers should seriously consider before implementing any policies that restrict access to biologic therapies. A 2014 study published by the American Journal of Pharmacy Benefits found that, following the introduction of biologics for treatment of RA, there was a notable reduction in total hip replacement and total knee replacement surgeries among RA patients, even though the annual number of such procedures almost tripled among other patients. These findings suggest that the availability of biologic agents, in addition to other changes in the therapeutic approach to RA, confers long-term benefits to RA patients and leads to cost savings in the health care system.
Another study published in the American Association for Hand Surgery found that the decline in the number of hand surgeries performed on patients with RA over a 22-year period correlated with the introduction of biologic therapies to treat RA — strongly indicating that these therapies have been successful at preventing the disease’s progression. These studies also confirm the widespread experience of practicing rheumatologists, who since the advent of biologic therapies no longer have their waiting rooms filled with RA patients in wheelchairs.
RA is a costly disease — both personally and to society writ large. Left untreated, it robs Americans of their mobility and ability to work and live a pain-free life. Arthritis and other rheumatic conditions remain the country’s leading cause of disability — generating more than $128 billion in annual health and indirect costs.
While we certainly can’t ignore — and must work aggressively toward fixing — the high cost of pharmaceuticals here in the United States, we will be taking two steps backward if we try to rein in costs by limiting patient access to breakthrough drugs for diseases like RA. These are expensive therapies, but they pale in comparison to the surgeries, hospitalization and life-long disability that many of our patients faced before the age of biologics.
Instead of trying to control drug costs by limiting patient access to therapies that we know are effective, it’s time for policymakers to focus on improving transparency among manufacturers and “middlemen” like pharmacy benefits managers, creating more competition through safe and effective biosimilars, and placing sensible parameters around utilization management and formulary practices in existing drug programs. It’s also time to protect patients by reducing their out-of-pocket costs and finding smart solutions that don’t miss the big picture.
David Daikh, MD, Ph.D., is president of the American College of Rheumatology.
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