It’s Time to Take Action for Patient Access

Since 2017, Let My Doctors Decide has been advocating for tens of millions of patients with autoimmune diseases and supporting a simple goal: treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or pharmacy benefit managers (PBMs). Unfortunately, that’s not always the case. Patients struggle with access barriers put into place by health insurers and PBMs who make it increasingly more difficult to access needed medicines, all while their disease progresses, and patients find themselves further away from wellness.

Over the past six years, LMDD’s efforts focused primarily on a handful of barriers including step therapy, prior authorization, and non-medical switching. Today, accessing doctor-recommended medicines is significantly more complicated and costly, with nearly a dozen restrictions – including copay accumulators, rebate walls or “traps,” “brown and white bagging,” and more complex appeals processes.

More barriers result in harmful outcomes as health insurance companies continue to “fail” their patients, confirmed by LMDD’s national scorecard study that found that three out of four plans scored a “C” or an “F” for treatment accessibility under their medical benefit for several autoimmune diseases. Results of recent national polling found health care consumers are extremely worried about these restrictions. Seventy-five percent are concerned that prior authorization, for example, can delay or block access to treatment, and 72% said they are worried that these practices can override doctors’ recommendations by allowing insurance companies to control treatment decisions. Additional research found that 90% of rheumatology providers said prior authorization decisions were delayed sometimes or most of the time, and nearly half the cases are denied by insurance companies and must go through an appeal process.

Congress and regulators are taking note. The Autoimmune Association (AA) and LMDD sent letters (here and here) to federal regulators urging meaningful changes to policies that continue to hinder patient access. Just last week, AA joined the PBM Accountability Project and more than 40 patient advocates, pharmacists, providers, and labor, anti-monopoly and employer organizations in sending a letter to Congress, calling for increased transparency and PBM oversight. Action continues, including a new bipartisan framework to rein in harmful PBM practices and this week’s Senate hearing and pending vote on a legislative reform bill that will make critical changes to how PBMs conduct business and interfere with doctor/patient decision-making.

AA and LMDD will continue to support and advance policies through our Patient Principles that put patients first and do not place unnecessary, harmful barriers to access between patients and their health care providers. For additional information, visit the LMDD website.