Millions of Americans Face Health Insurance Coverage Barriers; Formulary Contracting Increasingly a Concern for Patients and Doctors
WASHINGTON–(BUSINESS WIRE)–With health care set to play a major role in the national conversation in 2021, Let My Doctors Decide (LMDD) today urged policymakers, employers, and insurers to adopt a set of straightforward principles that address the barriers that prevent patients and doctors from making treatment decisions. This includes changes at the national and state levels that improve benefit design and ensure coverage that empowers provider decision-making, promotes access and adherence, and addresses affordability.
The announcement was made in conjunction with the virtual annual meeting of the American College of Rheumatology.
“Too often, health plans and policies imposed by pharmacy benefit managers and insurance companies undermine the clinician/patient relationship and the positive health and economic benefits that could follow,” said Randall Rutta, Executive Director of LMDD. “Clinicians and patients need the ability to make decisions when it comes to health and wellness, especially as society is grappling with the challenges of today’s COVID-19 environment.”
Today’s announcement builds upon LMDD’s principles developed last year that are designed to break down step therapy requirements and other access barriers that insurers and pharmacy benefit managers (PBMs) impose as part of a health plan or drug formulary. The updated principles that put patients first:
- Require that step therapy policies are clinically based on current evidence and used for medical reasons only.
- Prohibit switching of medication for non-medical reasons without the prescribers’ consent.
- Leave the final decisions to whether a patient has failed on a therapy with the treating physician, not the insurer.
- Pass rebates, discounts, copay assistance, and other insurer and non-insurer savings directly to the patient at the pharmacy counter.
- Assure that what is best for the patients’ health, as determined by patients and their treating physicians, is top priority and is made transparent in health care contracting, including benefit design and coverage policies.
“We urge insurers, PBMs and decision makers in government to adopt these principles,” said Rutta. “Doing so will eliminate unwarranted utilization management restrictions, rebate walls, and other practices that get in the way of individualized patient-centered treatment. It’s time to put patients first, change the status quo, and alleviate access barriers to enhance patients health and wellness.”
For more information, including a recent discussion with leading rheumatologists, health care managers, and patient advocates on the harmful impact of access restrictions, visit https://www.lmdd.org/escape-the-system/.
About Let My Doctors Decide
Let My Doctors Decide is a national partnership of leaders across health care working in support of a simple goal: treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or pharmacy benefit managers. LMDD is led by American Autoimmune Related Diseases Association in partnership with other associations and patient-focused groups that offer resources to patients and physicians about navigating the healthcare system when faced with a chronic autoimmune disease.
Brett McReynolds; email@example.com; 615-594-0145