As many as 50 million Americans are living with some kind of autoimmune disease illnesses in which dysfunctional immune systems attacks healthy tissues and organs, leading to painful, life-affecting conditions like psoriatic or rheumatoid arthritis, multiple sclerosis and Crohn's disease. These diseases are difficult to diagnose, complicated to treat and usually involve painstaking work by physicians to determine just the right medication, or combination of medications, that will bring the autoimmune sufferer some level of relief and the ability to live as close to a normal life as the illness will allow.
Many of these patients are unaware that their health insurance companies are restricting access to the treatments their doctors have deemed most effective. A disturbingly high number of health plans are geared to override the judgment of physicians and give patients the medicines that they—the insurers—want them to take. For those with complex autoimmune challenges, the ramifications of taking the wrong medicine can be severe.
A research team from Emory University evaluated the formularies of thousands of private health plans and Medicare coverage plans, specifically looking at the access they provide to medicines for five serious autoimmune conditions. The results are both startling and distressing.
The vast majority of private health plans and insurance options in the Medicare Part D prescription drug program impose significant to austere restrictions on access to treatments for these autoimmune conditions. In fact, fewer than 3% of plans nationwide offered what we would define as meaningful access to medicines at the pharmacy. Interestingly, these plans offer much broader access to medicines administered in a hospital or physician's office.
It's at the pharmacy counter where these access restrictions have the greatest detrimental effect on patients.
Some plans require the cumbersome, time-consuming process of prior authorization before patients can begin taking the medicines their physicians deem essential. Some require higher out-of-pocket spending for certain drugs in an effort to drive patients toward therapies that are better for the insurer's bottom line. And then there is the particularly insidious policy known as step therapy, "or fail first," in which patients are forced to try insurer-preferred medication options first until they have proven to be harmful or ineffective, at which point, they can finally transition to the medications their doctors initially ordered. Needless to say, these delays are significantly more harmful for individuals already suffering from a serious illness.
Patients also run into what is known as the "rebate wall." Health insurers and pharmacy benefit managers negotiate sizable rebates on particular drugs and then direct their patient-customers to use those drugs because greater utilization means more rebate dollars going into their bank accounts.
Just because certain treatments haven't achieved volume in the marketplace doesn't mean that patients shouldn't have access to them. Oftentimes, these medications—which can include less costly generics and complex biosimilars for autoimmune diseases—are the catalysts for future innovation. Restricting access can equate to less R&D investment over time, which slows the pace of innovation.
We initiated and are sharing this research because this trend warrants closer examination and concern. There are currently proposals being considered at the federal level that would expand coverage restrictions to more patients dealing with serious illnesses. The CMS is considering changes that would allow Medicare Part D plans to cover fewer medicines and use approaches like step therapy for more therapeutic classes of medications. These changes would apply to Medicare beneficiaries who are already stable and doing well on the medications they are currently taking, forcing changes that could disrupt their care and undermine their health.
This research and countless patient case studies should prompt a discussion of how we define health insurance and as how we, as a nation, strive to improve population health and responsibly reduce healthcare costs. Making people sicker by manipulating the medicines they take for financial gain would seem to be a flawed strategy if our goal is indeed to have a healthier America.