Study: Payers, PBMs hinder drug access for autoimmune patients

Health insurers and pharmacy benefit managers are not making the grade when it comes to access to medications for autoimmune diseases, according to a new study. But insurers say the study doesn't paint the full picture.

Research from a team at Emory University found that most private and Medicare plans are limiting coverage on medications for five of the most serious autoimmune diseases: Crohn’s, multiple sclerosis, psoriasis, psoriatic arthritis and rheumatoid arthritis.

The study looked at several coverage limitations including authorization, formulary status, tier placement and step therapy. The report also coincides with a new national initiative known as Let My Doctors Decide, which will focus on educating patients and doctors about step therapy, proposing solutions to prevent payers and PBMs from pushing step therapy and providing resources to help patients overcome access issues.

The researchers worked with an organization that collects benefits design data for all of the healthcare plans available in the U.S. For the report, researchers specifically looked at data on the prescription drugs administered in pharmacies and in hospitals for these specific diseases.

The team first assigned numbers, 0 to 4, for certain plan design features. For example, if a plan used step therapy, it was awarded one point. Requiring prior authorization for these drugs was also worth one point, as was a pharmacy tier design that did not include certain medications. In other words, lower scores reflect fewer access restrictions and higher scores reflect multiple access restrictions.

The numbers were then added up, and each plan was given a score of A, B, C or F. For example, an A was granted for one or fewer points and B for one or two points, etc.

In the end, 86% of Medicare Advantage plans received an F for coverage of autoimmune drugs and 48% of private insurers received an F. Within private insurers, another 50% of companies rated a C and not one received an A.

Conversely, coverage of autoimmune treatments administered by hospitals was quite high, with 73% of Medicare Advantage insurers getting an A for in-hospital pharmacy medication coverage, and 40% of employee-based insurers receiving an A.

“The bottom line is access to meds are better through the hospital benefits design than the pharmacy design,” Kenneth Thorpe, Ph.D., told FierceHealthcare. Overall, 97% of Medicare plans received a letter grade of C or F for plan design, and 98% of private payers received a C or F.

“In fact, fewer than 3% of plans nationwide achieved scores less than  2, a benchmark indicative of meaningful access to medicines at the pharmacy,” the study stated. “Both Medicare Part B and commercial health plans impose fewer restrictions on access to physician-administered medicines covered under a plan’s medical benefit, in contrast to most plans imposing severe to austere restrictions.”

Thorpe was surprised by the number of plans still using step therapy. With 90% of the healthcare spend in the U.S. linked to chronically ill patients, Thorpe says the country needs a new benefits design system, one void from prior authorization, high deductible plans and medication roadblocks.

The authors of the study speculate that patients who need medicines within the six protected classes of Medicare Part B may see higher access restriction in the future if step therapy is expanded and treated like Part D—which has been proposed by the current administration.

“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,” Randall Rutta of Let My Doctors Decide said in a statement.

Let My Doctors Decide is a patient advocacy group led by the American Autoimmune Related Diseases Association. The idea is to offer resources to patients and physicians about navigating the healthcare system when faced with a chronic autoimmune disease. A pilot of the program began in Michigan in 2017, offering local resources for patients.

“We understand from experiences that as much as patients are encouraged to be involved in their health and what might be the best intervention or health plan design, insurance can still cause problems,” Rutta told FierceHealthcare. If a patient is on a medication for an extended period of time and then a new health plan makes that drug unavailable, the alternate treatment can set a patient back or cause irreparable damage.

Rutta notes that physicians often first go down the least-expensive track or start with the medications supported by a patient's pharmacy benefit manager. But for a large portion of the population, this route does not make sense, Rutta said.

Thorpe also notes that benefit design needs to be more individualized. He says there are no average patients, so there's no one-size-fits-all approach—matching patients to appropriate medications takes work. Plus, policymakers and insurers need to recognize that finding the appropriate drugs means fewer drug reactions, fewer hospitalizations, fewer emergency department visits—and less total costs to the healthcare system, Thorpe said.

Randall agrees that physicians naturally gravitate toward step therapy treatment, and with 20% of the population suffering from chronic conditions, individuals need more personalized interventions. But several advocacy groups do not agree.

“PBMs are the primary advocates for consumers and health plans in the fight to keep prescription drugs accessible and affordable, and serve as the only check in the prescription drug supply chain against drugmakers’ sole power to set and raise prices,” a spokesperson for the Pharmacy Care Management Association told FierceHealthcare.

“Utilization management strategies in formularies are widely accepted in the health care community as essential in curbing abuse and reducing drug costs while maintaining high-quality pharmacy benefits. Formulary management tools, including prior authorization, protect patients’ health and lower prescription drug costs,” the spokesperson said

America’s Health Insurance Plans (AHIP) also weighed in on the report card, noting the methodology of the study “doesn’t seem to tell the whole story.”

“We can all agree doctors provide important care and life-saving treatment. They help get us healthy when we’re sick and keep us healthy when we’re well. But like everyone in health care, they can do better, too. Misaligned incentives and an incomplete view of a patient’s medical history often leads to too much care, or worse, harmful treatment,” a spokesperson for AHIP told FierceHealthcare.

Independent studies show that variations in treatment can lead to unnecessary, costly or inappropriate medical treatments. In fact, 65% of physicians themselves have reported that at least 15% to 30% of medical care is unnecessary. Plus, other studies show physicians can prescribe the wrong treatment due to lack of expertise or evidence.

“We can all do better to improve patient health,” the AHIP spokesperson added. “Just like doctors use scientific evidence to determine the safest, most-effective treatments, health insurance providers rely on data and evidence to understand what tools, treatments, and technologies best improve patient health. Insurance providers partner with doctors and nurses to identify alternative approaches that have better results and improve outcomes.”

AHIP believes prior authorization and step therapy are necessary steps to ensure patients receive care that is safe and effective.

This article originally appeared in FierceHealthcare.