Prior authorization treatment delays, the preferred status conferred on some drugs by pharmacy benefit managers and exorbitant co-payments were among the issues brought before the U.S. Senate Special Committee on Aging on Wednesday, Feb. 7. William F. Harvey, MD, MSc, FACR, a practicing rheumatologist at Tufts Medical Center in Boston and volunteer on the ACR Board of Directors, testified before the committee, highlighting issues of import to rheumatologists and their patients.
“Choosing the right therapy for a patient is a complex medical decision that considers other conditions and medications the patient may have, balancing the risk of side effects and many patient-specific factors,” said Dr. Harvey. “… Factors to consider when choosing the right biologic therapy include medications already tried, history of infections and malignancy, and the ability to administer the medication to themselves. But overwhelmingly, the primary factor in the decision is which one is covered best by insurance. …
“Each of these medications require a prior authorization. Each insurance company has a different set of forms requiring somewhat different types of information. Most require that the patient have their medication provided by a specific pharmacy. This is because the insurance companies negotiate, often through pharmacy benefit managers, price discounts in exchange for preferred status on the insurance formulary. If a provider wishes to prescribe a medication that is not preferred, the prior authorization will be denied, and the provider must go through an escalating appeals process that may involve talking to a clerk, a pharmacist, a nurse, a “peer review” (another MD but typically not a rheumatologist), a same specialty review and, in the case of Medicare, an Administrative Law Judge.”
Dr. Harvey asked the committee for regulations requiring that insurance companies follow a standard, transparent process for documenting, evaluating and approving prior authorization requests.
Dr. Harvey also endorsed the Patient Access to Treatment Act (H.R. 2999) or other efforts that limit or cap out-of-pocket expenses for patients, saying that co-pays “were originally conceived to require consumers, patients, to have some skin in the game.” But out-of-pocket expenses for rheumatology patients are substantial, said Dr. Harvey. “Patients did not choose their disease, nor do they control the high cost of developing and marketing the only therapies left to treat their condition. Asking them to pay their ‘fair share’ is immoral and indefensible when it leads to medical bankruptcy. Further, these patients are more likely to leave the workforce, ending up on government subsidized disability, which further burdens the federal government. I can say unequivocally that many patients with rheumatoid arthritis or its close cousin arthritis associated with psoriasis, that many patients have no skin left to give.”
