Let Doctors Decide Treatment Regimens, Not Insurance Companies and PBMs

Patients suffering from autoimmune diseases face a number of challenges every day, and unfortunately, the situation is not improving. New research reveals that most of the nation’s top health insurers are failing to provide access to medicines at the pharmacy counter, making it increasingly more difficult for patients with complex diseases to get the medications they need.

A new study and report card analysis based on research from a team at Emory University, recently released by Let My Doctors Decide, revealed the extent to which private and Medicare health plans utilize coverage limitations on medicines 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 — an insurance company practice that requires patients, many of who are seriously ill, to try a series of drugs before covering the cost of doctor-recommended medicines.

The new research illustrates how the vast majority of private and Medicare health plans impose considerably harmful restrictions on access to the most appropriate medicines for the diseases analyzed in the study. According to the research, 86 percent of Medicare Advantage and Part D plans received a failing grade – an “F” – for access to medicines at the pharmacy. Interestingly, all plans within Medicare Advantage and Part B received an “A” for access to medicines that are administered in a doctor’s office.

For patients who have already seen their health, careers and personal lives suffer due to their medical conditions, delaying corrective treatment results in deteriorating health and increased medical consequences. 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.

One obvious solution is to give doctors more control over the medication and treatment that patients receive, for example, by allowing doctors to override step therapy if they expect a treatment to be ineffective or to give them input on the development of step therapy guidelines. Returning control to doctors over treatment decisions acknowledges their medical expertise — professional training that insurers do not have — and recognizes that this knowledge is critical to determining how to best meet patients’ needs.

Letting doctors decide on medical approaches also preserves the doctor-patient relationship, which is especially important for patients with rare or hard-to-diagnose chronic conditions. This includes individuals with autoimmune diseases, who often must spend significant time working closely with doctors to diagnose conditions and find an appropriate treatment.

Of course, one sure way to eliminate these concerns is for insurers to simply eliminate step therapy requirements and trust that doctors will work with patients to find the most effective, sensible treatment for their unique situations. Accelerating insurers’ response time to appeals from patients who have questions regarding step therapy rules would also be helpful in reducing risks associated with this harmful practice.

This new research and prior studies indicate that the burdensome health insurance practice of step therapy is disproportionately affecting patients whose conditions require specialty medicines. All patients deserve access to all available medicines. They also deserve to receive the treatment their doctors determine is best for them in a timely manner — regardless of their medical condition.

There are solutions to ensure that step therapy practices are applied only when appropriate and avoid unnecessary patient suffering. It is time to start examining these alternatives and letting doctors and their patients decide the best possible solution.


Virginia Ladd is the executive director of American Autoimmune Related Diseases Association.

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