New National Polling and Research Illustrates Harmful Payer and PBM Barriers that Continue to Plague Patients
A Penn State college student was denied coverage for doctor-recommended medicines for his chronic autoimmune disease, and filed a lawsuit against his insurance company because the payer deemed the cost too expensive and refused to cover the life-saving drug.
A health/science reporter battled her insurance company for months while her 3-year-old son’s rare form of juvenile arthritis progressed because the insurance company would only cover a medicine he was previously on which did not work, and refused to pay for a new biologic treatment recommended by medical experts.
These stories and thousands of others are painful examples of utilization management practices used by insurance companies and pharmacy benefit managers (PBMs) that prevent patients from accessing doctor-recommended medicines and treatments, further delaying health and wellness.
Prior authorization, for example, requires doctors to obtain specific approval from health insurers before they are able to prescribe a treatment to their patients. This process not only requires health care providers to take valuable time away from patients, but it can also lead to negative health outcomes.
A recent national poll by Lake Research Partners and the Tarrance Group, commissioned by Let My Doctors Decide, found that:
75% of health care consumers are concerned that prior authorization (PA) can delay or block patients’ access to treatment.
71% are worried that PA will increase patient costs.
74% expressed concern that PA can require patients to substitute less effective or ineffective treatments for what their doctors prescribed.
72% said they are concerned that such policies can override doctors’ recommendations by allowing insurance companies to control treatment decisions.
Related research conducted by Xcenda of rheumatology providers in several states found significant delays in the vast majority of PA decisions requests as a result of insurance company and PBM requirements.
90% of rheumatologists say PA decisions are delayed sometimes or most of the time.
Nearly 50% of cases are denied by insurance companies and must go through an appeal process.
In the majority of requests, payers require proof that the patient has failed on a medicine or treatment before the payer will consider the request.
“Fail first” practices -- known as step therapy -- requires a patient to fail on a drug or treatment before the insurance company will agree to cover the original doctor-recommended medicine, further delaying health and wellness and putting at risk the critical doctor-patient relationship.
The polling and research findings are in line with results of the recent LMDD national health insurance scorecard which found that three out of four insurance plans received a “C” or “F” because of PA and other access restrictions placed on patients.
Patients, providers, and other stakeholder groups continue to support reforms and meaningful changes to utilization management policies. LMDD’s 2023 Patient Principles recommends policy changes and heath care plan design reforms to alleviate harmful access barriers and level the playing field for patients, including the more than 50 million with autoimmune diseases.
