Giving patients the healthcare system they already think they have

October 6, 2020

The COVID-19 crisis is a disturbing eye-opener for many Americans as they discover that the public health protections they have always believed were in place may not exist. This raises public awareness that long-held beliefs about our healthcare system - for example, that physicians and patients make the decisions on the best course of treatment - are, in fact, fallacies.

The Centers for Disease Control and Prevention has made clear that among those at higher risk from COVID-19 are people with serious underlying medical conditions. It is more important than ever that physicians have the latitude to make the most effective medical decisions on behalf of their patients, and that patients have the security of knowing their well-being is protected by doctors who know their medical histories. 

In too many cases, doctors are not in the driver’s seat in deciding how to most effectively meet patients’ needs. Physicians must navigate through a maze of barriers constructed by insurers and pharmacy benefit managers to prescribe the medicines physicians deem most suitable. Frequently, drugs are covered not on the basis of medical expertise, but rather on negotiated deals and high profit margins for certain medications.

It is essential that health insurers and PBMs rethink and revise current practices that limit patient access to treatments, overriding what physicians deem the most effective options. These practices include step therapy, or “fail first,” policies, in which patients must utilize the medication preferred by the insurer - usually for financial reasons - and cannot transition to a different drug until the first medicine has been proven ineffective or has caused harmful side effects. Often these protocols are driven by another harmful practice known as “rebate walls,” which forces patients to use a drug for which the insurer or PBM has negotiated the most profitable rebates. 

Patient groups and other advocates applaud policymakers in Delaware who recognized the unnecessary, costly ramifications these harmful practices have on patients and healthcare providers. Last year, a step therapy reform bill unanimously passed the House and Senate, and the bill became law June 1. This new law allows Delawareans to access medications and treatments recommended by their doctors without having to maneuver through step therapy protocols and other restrictions. 

Policymakers and regulators at the federal level can also take actions that will help patients, particularly those most vulnerable to COVID-19 and those with autoimmune diseases. Mandatorily lifting requirements for prior authorization would be immensely helpful during this global pandemic and would alleviate additional work for doctors, and ensure patients have access to recommended medicines and treatments.

Patients should also be permitted to continue on medicines and treatments that are working and not have to get additional approvals from insurance companies for something that has proven successful. And, insurance coverage for in-home infusion treatments must be implemented for patients in lieu of having to go doctors’ offices, clinics, or hospitals that are already overtaxed and could further expose at-risk patients.

It is unconscionable, particularly given the current public health emergency, that patients continue to experience barriers to doctor-recommended medicines, forcing them to utilize medicines and treatments that may worsen their symptoms before they are allowed access to the preferred medicines, leaving them more vulnerable to serious health problems.

The ability of patients and physicians to make decisions about the best course of care must not be undermined by companies acting out of financial motivations. Patient groups and other partners welcome the actions in Delaware and other states, and look to Washington to examine the policies and practices that obstruct patients’ ability to access medicines and treatments recommend by their doctors and take the necessary actions to put patients first.It’s time to give patients the healthcare system they already think they have.

Randall Rutta is the president and CEO of the American Autoimmune Related Diseases Association.
  • Cape Gazette commentaries are written by readers whose occupations, education, community positions or demonstrated focus in particular areas offer an opportunity to expand our readership's understanding or awareness of issues of interest.

Subscribe to the Daily Newsletter