Providers Speak Out
Prior authorization barriers create obstacles in the ability of vulnerable seniors and disabled beneficiaries to access medicines, resulting in treatment delays that can have deadly consequences.
Part B Access for Seniors and Physicians Coalition
Patients Speak Out
Step therapy once delayed my ability to get effective treatment for more than a year. As a result, the debilitating effects of my disease continued to worsen while I also suffered the side effects of a drug that did not work for me.
Elizabeth Krempley, rheumatoid arthritis patient and Arthritis Foundation advocate.
Utilization Management
— Obstructs Treatment Plans —
— Compromises Medical Decision Making —
Utilization Management is a term that refers to rigorous, one-size-fits all treatment protocols established by health plans to control costs at the sake of patient need.
These restrictive techniques can take the form of Prior Authorization, Step Therapy and White Bagging.
PRIOR ATHORIZATION
Prior Authorization places a middleman at a health plan in the center of medical treatment decision making. A health plan administrator who has never actually placed hands on the patient, evaluated lab and imaging test results, or studied a patient’s unique medical history must approve treatment and care prescribed by a physician before that care can be delivered. This delays patient care and discredits medical specialists’ expertise, experience and extensive training.
Physicians lean heavily on their medical expertise and years of training when confronting challenges that require them to ‘think outside the box’ for their patients. In some cases, this might mean highly specialized combinations of drugs or using a well-known therapy in a novel manner. Unfortunately, insurance plans often balk at coverage of these treatment options even though they may be the only alternative to provide patients with relief.
Restrictive prior authorization policies enable bureaucratic middlemen to interfere with the carefully crafted, individualized treatment plans physicians develop for their patients. As medicine advances and treatment becomes more personalized, it is more important than ever that the treatment plans physicians tailor for patients are not obstructed due to bureaucratic utilization management policies such as prior authorization. Patients and providers – not middlemen driven by cost containment goals – should always remain at the center of medical decision making.
STEP THERAPY
Step therapy, or “fail first,” is a utilization management technique used by health plans. Much to the frustration of physicians and even to the detriment of patients’ health, when a physician prescribes a particular drug treatment for a patient, the patient’s insurance company may require them to try different medications and treatments (and first fail on them) before they can access the drug originally prescribed by their physician.
This can result in a patient going through months of ineffective treatment with second or third choice medications before the drug therapy, originally prescribed by the doctor, is finally covered. Health setbacks and disease progression, patient copayments and cost sharing accompany these many rounds of ineffective prescriptions.
Physicians prescribe specific procedures, drug regimens and courses of treatment based on the unique characteristics, genetics and health history of individuals in their care. Patient’s should have timely access to the therapies that their physician determines will best treat their ailment.
The search to find an effective treatment for some diseases, including forms of arthritis, Crohn’s disease, epilepsy, and cancer, can prove to be a long, frustrating process. Not all medications are tolerated by all patients; the disease might be the same but each patient is unique. To find the right medication for a patient’s particular condition, physicians relay on their expertise, experience and extensive training.
Patients lose when their physician’s medical expertise encounters rigid, unworkable, cost-containment benchmarks of an insurance plan. In some circumstances, step therapy protocols may ignore a patient’s unique circumstances and medical history. Patients may experience severe side effects and irreversible disease progression from trying and failing on several alternate therapies before ultimately receiving the most effective, physician-prescribed treatment.
WHAT IS WHITE BAGGING?
Under a “white bagging” arrangement, a patient’s health plan requires the prescribed medication to be purchased through the plan’s exclusive specialty pharmacy and then it is shipped to the patient’s physician’s office for administration to that specific patient.
This complex requirement interrupts the normal course of treatment and interferes with the patient’s medical team providing the best possible care and service to the patient.
Patients with complex conditions like cancer, rheumatoid arthritis, autoimmune conditions, allergies, and eye diseases require drug treatment that must be administered by physicians or infusion clinics. At these practices and clinics, highly trained physicians safely stock, monitor, and administer patients’ treatment. This enables day-of appointment dose adjustments and drug substitutions or additions to be made when necessary. This flexibility allows providers to effectively treat the unique needs of each patient and their disease and ensures timeliness of care – critical components of successful treatment. White Bagging strips away this flexibility and results in treatment delays, drug waste, threats to patient safety and increased patient copays.
White Bagging = Risk
White Bagging Impact on Patients
White Bagging policies fracture the trusted physician-patient relationship.
“In some cases, the providers are barred entirely from administering drug therapies to their critically ill patients and instead must direct their patients to seek care at unknown specialty pharmacies owned or affiliated by the health plan.” – American Hospital Association
White Bagging Impact on Providers
The Coalition of State Rheumatology Organizations (CSRO), dedicated to ensuring access to the highest quality rheumatologic care, has expressed “Under the white bagging model practices do not have control over the handling, preparation, and storage conditions of the drug prior to its administration. Improper handling on the part of a specialty pharmacy can have serious consequences for patients, and white bagging removes practices’ ability to prevent adverse events through internal oversight.”
SOCIAL FEED
PROVIDERS SPEAK OUT ON STEP THERAPY
A patient’s health care provider is in the best position to assess their patients’ medical needs. – sentiment expressed by 58 medical specialists and provider groups that treat nearly every body system.