Opinion: Health Insurance Too Often Fails To Make The Grade

Movies and TV shows show insurance companies denying care to seriously ill people to save money: the exception, not the rule. Today, we know more about the prevalence of health care provider practices that delay needed care for Americans with life-changing conditions.

Research shows how our health insurance system is failing more than 50 million people with autoimmune diseases. The National Scorecard analyzed insurance plans from well-known companies, including AARP, Aetna, Cigna, Elevance Health, Humana and United Health Group. Those plans cover more than 100 million people, and the report found that insurers have created barriers that make it harder for patients to get prescription drugs.

This dashboard aggregated drug and medical benefits data from thousands of plans and pharmacy benefit managers (PBMs) and analyzed drug coverage limitations for various autoimmune conditions and access barriers. These include: step therapy, which requires patients to use their drug of choice until "first failure" before accepting treatment prescribed by their doctor; The level of expertise that certain medications put into formulary carries a significant financial burden; and prior authorization, which requires insurance approval before doctors recommend treatment.

Three of the four plans received a "C" or "F" for patients receiving treatment directly prescribed by their doctors. 25% of business plans received an "A" or "B" grade compared to 17% of business plans. Additional research from rheumatology providers has found that 90% of prior authorization decisions are delayed and half are denied by insurance companies. Rheumatologists point out that most applications require patients to fail before the insurance company or PBM will review the application.

It's not just about depriving patients of their ability to overcome their symptoms. Many new autoimmune treatments reverse the disease and stop its progression. Without timely and appropriate treatment, organ systems can be damaged. For example, untreated rheumatoid arthritis can lead to joint replacements, requiring additional services and limiting your ability to work.

Fortunately, we are starting to see progress. The Senate Finance Committee, of which Sen. Mark Warner of Virginia is a member, released a legislative framework for policy reforms to hold PBMs accountable. Sen. Tim Kaine of Virginia and other members of the Senate HELP Committee have asked PBMs tough questions and passed a bill to limit policies that cut drug access and drive up costs. Similar measures are expected in the House of Representatives and in several states, including Virginia.

The public agrees that these actions cannot happen soon enough. According to a recent survey, a majority (71-74%) of consumers are concerned that prior authorization will delay or block access and increase costs, causing patients to delay treatment or receive less effective treatment. PBMs and insurance companies make treatment decisions based on physician recommendations. According to the survey, the vast majority agreed with the need for reforms, including that insurance companies respond to emergency claims within a certain period (80%); Insurance companies need easy access to pre-consent information (80%); and insurance companies that use electronic systems to speed up the process (77%). The public is mostly supported by insurance companies that cover all FDA-approved prescriptions and care (79%).

Support for curbing reforms cuts across demographics and political affiliations, a rare issue that attracts strong bipartisan support. Health insurance should give patients peace of mind that they and their doctors will have access to the care they deem necessary and appropriate. Instead, current payment practices cause unnecessary financial burdens and emotional distress, which exacerbates medical problems. Policy makers must act to prevent more people from being needlessly injured.

Dr. Harry L. Gewanter is a semi-retired Richmond pediatric rheumatologist and director of the Coalition of State Rheumatology Organizations. Molly Murray is the President and CEO of the Autoimmune Society.

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