When it comes to healthcare, America is facing a number of crises. The COVID-19 pandemic has upended our system and inflicted pain and uncertainty on millions of families. A decade after the Affordable Care Act became law, too many Americans still don’t have access to the care they need, particularly communities of color.
These are the crises we hear and read about.
Yet there’s an underlying flaw that shows itself each day across our healthcare system, one that goes to the heart of why healthcare exists and what it’s designed to do. Namely, doctors and patients are increasingly left out of the decision making process and face insurmountable barriers to getting treatments that are needed to address serious chronic diseases and stay healthy.
Beyond talk
Despite the partisan rhetoric over health policy and competing plans to fix it, meeting the dual objectives of better healthcare and lower costs isn’t all that complicated. It simply requires something as fundamental as letting doctors determine what treatment regimens are best for their patients, and giving patients access to the proper treatments and services that will keep them out of hospital beds, emergency rooms, and the type of acute care settings that drive up the nation’s healthcare tab.
Let My Doctors Decide — a coalition of leading patient and provider advocates — developed a set of straightforward principles last year designed to break down access barriers that insurers and pharmacy benefit managers impose as part of a health plan or drug formulary. They include the importance of patients and physicians making individual treatment choices, not treating all autoimmune diseases the same, ensuring access to easily understood information about coverage, and directing negotiated discounts, rebates, and other insurer and non-insurer savings to patients at their pharmacy counter.
It’s now time for a call to action. The Centers for Medicare and Medicaid Services, employers, health insurers, and decision makers at all levels must embrace changes that, in the long run, will reduce health costs by keeping patients healthier and avoiding the need for expensive interventions.
Eliminating bad policy
This includes addressing contracts that use rebates or volume discounts to exclude therapeutic options from formularies. They should be strictly prohibited. These financial dealings that direct patients toward a prescription drug, the manufacturer of which offers PBMs the strongest financial incentives, will stifle competition, increase costs, and harm patient health.
We also need to correct step therapy — “fail first” policies — that makes patients take multiple drugs preferred by their insurer, and suffer health setbacks because of them, before they can access the medicine prescribed by their physician.
Recent analysis of rheumatoid arthritis treatments found that 78 percent of 213 commercial coverage decisions reviewed require step therapy. Twenty-five percent of these coverage policies require three or four steps prior to access to a specific rheumatoid arthritis treatment, and 43 percent of all coverage decisions require at least two steps.
Reducing costs
Drug affordability for patients is key and will increase the likelihood of adherence to the treatment protocol developed by the physician. Out-of-pocket costs can be lowered by eliminating excessive cost-sharing requirements, passing rebates on drugs directly to the patient at the pharmacy counter, and prohibiting limitations on the use of co-pay assistance programs.
Without question, healthcare is a complex and often controversial topic that generates, at times, heated political division. But improving a severely flawed status quo doesn’t have to be all that complicated or difficult. It really boils down to trusting and empowering the physician-patient relationship, and removing barriers to healthcare that will keep patients healthy and avoid incurring unnecessary medical costs.
As we enter a new phase of COVID-19 and prepare for a year in which healthcare will again be front and center, let’s put patients first and make the patient-physician relationship a top priority. Nearly everything else we do depends on it.
