Transparency and Reforms Needed to Improve Health & Lower Patients’ Costs
By Randall Rutta
Putting patients first. That was the Let My Doctors Decide mission when we launched nationally a few short years ago, and it remains true today. This national partnership of leaders across all health care continues to promote change to ensure that treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or Pharmacy Benefit Managers (PBMs).
Health care coverage must be closely aligned with affordability to promote individual and population health while managing overall costs. Unfortunately, that’s not always the case as harmful access restrictions put at risk the critical doctor-patient relationship and result in higher costs for patients, even as we are grappling with the challenges of today’s COVID-19 environment, with detrimental effects on health and economic benefits.
These unnecessary barriers include harmful step therapy practices that require patients to “fail first” before their insurance company will authorize the medicines and treatments originally prescribed by their health care providers. Recent analysis from the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center of rheumatoid arthritis treatments found that 78 percent of 213 commercial coverage decisions reviewed require step therapy. Twenty-five percent of these coverage policies require three or four steps prior to access to a specific rheumatoid arthritis treatment, and 43 percent of all coverage decisions require at least two steps.
Today, Let My Doctors Decide announced a set of enhanced principles that are designed to break down access barriers that insurers and PBMs impose as part of a health plan or drug formulary. The LMDD principles:
Require that step therapy policies are clinically based on current evidence and used for medical reasons only.
Prohibit switching of medication for non-medical reasons without the prescribers’ consent.
Leave the final decisions to whether a patient has failed on a therapy with the treating physician, not the insurer.
Pass rebates, discounts, copay assistance, and other insurer and non-insurer savings directly to the patient at the pharmacy counter.
Assure that what is best for the patients’ health is the top priority and is made transparent in health care contracting, including benefit design and coverage policies.
These essential reforms will eliminate unwarranted utilization management restrictions, rebate walls, and other practices that get in the ways of individualized patient-centered treatment. This includes changes at the federal and state level -- supported by the Centers for Medicare and Medicaid Services, employers, health insurers, and decision makers -- that are transparent in benefit design and coverage that empowers provider decision-making, promotes access and adherence, and addresses affordability.
It’s time to put patients first and change the status quo to preserve the provider-patient relationship and alleviate access barriers to enhance patients health and wellness.
Randall Rutta is the Executive Director of Let My Doctors Decide.