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Insurers and pharmacy benefit managers (PBMs) in search of profits are preventing patients from getting the drugs they need, according to the latest episode of the I am BIO Podcast.
Utilization management practices, like step therapy and prior authorization, mean that patients are denied the drugs their doctors prescribe, explain podcast guests.
Deb Constein of Madison, WI, describes her experience with step therapy—being forced to try other, cheaper drugs before she was allowed to take the drug her doctor said she needed.
Suffering from arthritis since the age of 13, Constein developed stomach damage from aspirin and other “old-fashioned” painkillers. She eventually contracted painful gastroesophageal reflux disease. She was put on expensive medication, but after a while, the insurance company would not cover that medication because they thought she should have healed.
“They made me go all the way back to Zantac, which is the most basic over-the-counter medication,” Constein says. “My husband fought with them over and over, saying, ‘You don’t understand what is happening in our life.’ I felt like I was having a heart attack. The pain was so intense in my sternum area, and they still said, ‘You need to do a retrial.’”
Although the condition was debilitating, Constein was made to try several different medications—and have a colonoscopy and endoscopy—before the insurer finally let her take a more expensive drug.
“It was very frustrating during this time. It cost the healthcare system thousands of dollars as far as more diagnostics to show that no, there wasn’t healing, and I still did need a higher-tier medication,” she says. “They clearly set the patient aside. It’s all about money, and that’s what it literally came down to.”
‘What are we even doing?’
Dr. Harrison Nguyen, a dermatologist, clinical researcher, and health economist from Houston, describes how utilization management impedes treatment.
“I spend a tremendous amount of time fighting with insurance, and it’s an ongoing dialogue with my patients and they’re aware of the burdens,” he says. “I have two full-time biology coordinators on my staff who we have to pay a full-time salary and benefits. And their whole job is to essentially fight with insurance to get patients access to medications.”
Nguyen recounts the situation of a patient with debilitating full-body atopic dermatitis. As nothing else worked, Nguyen sought to put the patient on a biologic medicine, but the insurer made the patient try drugs that had failed, despite his office writing to the insurer several times.
“Six months later, this patient still couldn’t get access to therapy. And so even though this patient is suffering, is losing sleep, isn’t able to work, we can’t get this patient on the right therapy. And this is a common story, something that we encounter on a regular basis,” says Nguyen.
Utilization management is particularly problematic in quality-of-life conditions like dermatology: “Insurers and PBMs may say that this isn’t going to kill the patient; therefore, we’re not going to pay for the best medication.”
Ultimately, utilization management is preventing doctors and drug makers from offering the right treatments.
“We can spend years in school becoming the best doctors that we can be. We can spend decades doing the best research we can to develop the best medications,” Nguyen says, “but if we don’t have a system that provides patients access to these therapies, what are we even doing?”
He called for a partnership between doctors and drugmakers to fight the ills of utilization management.
“We need to be advocating on Capitol Hill. We need to be meeting with our legislators to let them know these problem points that we have.”
Washington pushes back
Frank Watanabe, President and CEO of Arcutis Biotherapeutics, reminds listeners that drug development often fails, and when it succeeds, it takes an average of 10 years and about $2.5 billion to bring a drug to market.
“And then when you get it on the market, and your adoption is being restricted because of insurance companies, it has a significant impact on companies, and it has a significant impact on our ability to develop the next generation of treatments as well, because we’re investing our profits back into research and development.”
There has been some pushback in Washington, including the Federal Trade Commission’s report on PBMs and legislation proposed in Congress.
Watanabe mentions the Safe Step Act, which would allow patients to gain exceptions to step therapy, and legislation in the Senate to disincentivize pharmacy benefit managers from promoting drugs that are more profitable for them.
“I think that even if these bills passed, there’s still quite a bit more work to be done, and Congress is still holding hearings and evaluating this and trying to get to the truth of what’s really going on in the system,” says Watanabe.
It’s not enough for doctors and drug makers to call for reform. Patients also need to make themselves heard.
“If your doctor is changing your therapy or tells you, I think you should be on X, but you have to be on Y, that’s an opportunity for everyone to get involved,” he says. “Talk with the doctor about your options, about how you can get what he or she thinks is the best choice for you, and then let your Congress person and your senator know how unacceptable you think it is for the insurance companies to be manipulating your healthcare.”
