New Scorecard Highlights Access Barriers Faced by People Living with Autoimmune Diseases

Let My Doctors Decide – an initiative of the Autoimmune Association to raise awareness of insurer access restrictions – has rolled out a new scorecard assessing how much insurers and their pharmacy benefit managers restrict access to medications for patients living with some of the most common autoimmune diseases. The scorecard looked at access restrictions faced by patients living with Crohn’s disease, ulcerative colitis, lupus nephritis, multiple sclerosis, rheumatoid arthritis, psoriatic arthritis, and psoriasis. Approximately 15.9 million Americans¹ are estimated to be living with these conditions.

Three out of four plans scored a “C” or an “F” for treatment accessibility under their medical benefit for all conditions studied, whether covered by Medicare Advantage, commercial insurance, or a health exchange plan. This demonstrates how health plans give little deference to patient-physician decision-making in selecting medicines for autoimmune diseases, even for those administered in a doctor’s office. Further, few – if any – plan types received a “A’ grade across all conditions.

View the complete report.

The analysis looked at thousands of commercial (employer-sponsored & those available on state exchanges), Medicare Advantage, and Medicare Part D insurance plans available across the country as well as traditional Medicare. Using data provided by the analytics firm MMIT, LMDD assigned a grade to both the medical benefit and pharmacy benefit for each plan and for each condition.

Under the guise of promoting cost savings, many insurers use “utilization management” policies such as prior authorization, step therapy, and restrictive formulary placement to make it more difficult for patients to access needed medications. These policies often lead to delays in treatment with potentially health-damaging effects. This new scorecard shows that many well-known insurers like Humana, Aetna, Anthem, Cigna, and AARP are among those plans whose formularies put up significant access barriers.

The access barriers examined for the report include:

• Formulary/tier placement – Plans tier their formularies to incentivize use of preferred medicines based on different cost-sharing requirements for patients. Higher tiers typically represent higher cost-sharing requirements. Requiring high cost-sharing for patients can mean medicines are financially out of reach even though they are “covered” by a plan.
• Step therapy – Step therapy, also known as “fail first” policies, forces patients to try – and “fail” – one or more medicines preferred by the insurer before their insurer will cover the drug that the patient’s doctor initially prescribed. The policy undermines doctors’ clinical decision making, interferes with doctor-patient relationships, and makes it hard for patients to access medicines when they need them.
• Prior authorization – Insurance plans often require doctors to obtain specific approval from the insurer before they are able to proscribe a treatment to their patients. This time-consuming process not only requires doctors to take valuable time away from patients, but it can also lead to delays in treatment as patients must wait for the insurer to issue a response.

Let My Doctors Decide publishes resources to help patients navigate insurer access barriers. Check out the organization’s patient-friendly guidebook with information on how to navigate these access barriers.

View the complete report.

¹
1.5 million living with rheumatoid arthritis according to the Arthritis Foundation.
2.4 million living with psoriatic arthritis according to statistics from the National Psoriasis Foundation.
1.5 million living with lupus according to the Lupus Foundation.
1.6 million living with Chron’s & ulcerative colitis according to the Crohn’s & Colitis Foundation of America.
8 million living with psoriasis according to the National Psoriasis Foundation.
913,000 living with MS according to the National Multiple Sclerosis Society.