Neti Pots, Nurse Ambassadors & American Healthcare

Choiceless Choices

The bulk of the complaint, however, makes me wonder whether California’s attorney general (AG) has any idea what it is like to be a practicing rheumatologist. The AG seems to be laboring under the misunderstanding that, when a patient needs a TNF inhibitor, I am free to choose whichever drug I want. As you know, that is far from the case.

‘A nurse ambassador, who could potentially take many patient problems off my plate, might buy at least as much goodwill as a burger and fries.’

When I am planning to prescribe a TNF inhibitor, I make certain my note documents the treatment history, so it is clear to the insurer the patient has had an adequate trial of cheaper medications. Some of my colleagues go as far as to treat an especially active rheumatoid arthritis patient with both methotrexate and hydroxychloroquine, so the patient can simultaneously fail two medications, which is required by some insurers to green-light a biologic. My note will also document the patient meets the 2010 ACR/EULAR classification criteria for rheumatoid arthritis, even though ACR criteria were never intended to be used to determine which patients were worthy of treatment with a biologic.

That’s just the beginning. Whenever I write a prescription for a biologic, I warn the patient that it may be months before they receive the drug. Sometimes, the insurer wants more documentation that I know what I’m doing. Sometimes, the insurer wants me to first try another biologic, or another brand. Those decisions are largely made by the pharmacy benefit managers, which steer me to the drug that allows them to generate the greatest profit.

In theory, programs like nurse ambassadors may discourage clinicians from prescribing biosimilars. As a clinician, I know the decision to prescribe biosimilars has been taken out of my hands. Biosimilars were supposed to lead to $54 billion in cost savings in the U.S. In practice, widespread biosimilar use has been hindered by litigation that blocks their sale and by the pharmacy benefit managers who use the threat of biosimilars to drive down the price they pay for brand name drugs.⁹

Rituximab is a good example of this. Many of my patients now receive treatment with biosimilar rituximab, rather than the brand name agent. I just can’t predict which agent any given patient may receive. Counterintuitively, I find the pharmacy benefit managers will often insist I prescribe the brand name originator biologic, which is just further proof of how arbitrary drug prices really are.