When insurance company practices put patients at risk, advocacy is an important tool physicians can use to make a real difference. The ACR and its members are actively advocating for rheumatologists and patients on priority issues, including prior authorization, step therapy, drug pricing and out-of-pocket costs. By speaking up and engaging their patients, rheumatologists can help change harmful practices.
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Effects on Patient Care
Insurance company policies can negatively affect patient outcomes by delaying or altering treatment plans. Norman Gaylis, MD, the board liaison to the ACR Government Affairs Committee (GAC), sees delays in patient care at his Florida practice due to insurance requirements for prior authorization. The problem is especially pronounced early in the year, he says, because patients who change insurance plans must wait for new authorizations. In late January, numerous patients in his clinic were still waiting for treatment because their insurance companies had yet to provide authorization.
The increasing prevalence of step therapy policies is another area of concern, says Chris Phillips, MD, chair of the ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care. “Many of the step therapy requirements are not evidence based and oblige our members to abandon a planned treatment sequence based on clinical evidence and the provider’s experience,” he says. “And we know that opaque rebates between manufacturers and pharmacy benefit managers [PBMs] drive the tiering of drugs in these protocols.”
Step therapy policies can also lead to higher drug prices for patients. A medication required by an insurance company may be more expensive than an alternative recommended by the physician. In such cases, the patient ends up having to pay more to receive a non-recommended treatment.
High out-of-pocket expenses are another issue for patients. At Dr. Gaylis’s practice, some patients with new out-of-pocket requirements as of 2020 are finding their biologic therapies aren’t covered, he says. Practice staff try to help patients obtain free or reduced-cost treatments through foundations that support the cost of biological prescriptions. Without such assistance, however, patients may not be able to afford treatment.
The Importance of Advocacy
Effecting real change related to current priority issues is not easy, but it is possible through advocacy efforts. And there is strength in numbers, so the more people who get involved and speak up, the better the chances of success.
“The first step in advocacy is simply recognizing that it works,” Dr. Phillips says. “Only through our collective outreach—individually, as a group within rheumatology, and in the broader house of medicine—do things get done.”