CLEVELAND, Ohio - Medicaid patients with rheumatic diseases are not only battling their chronic conditions, but also their insurance providers in a fight for medications.
Rose Maloney's psoriatic arthritis leaves her in near constant pain. For 12 years, she has battled first with psoriasis and then with the onset of psoriatic arthritis, autoimmune diseases that give her severe joint pain and skin rashes. To treat her symptoms, doctors over the years have tried a number of medications, most of which only worked for a few months.
Two years ago, she was put on Cosentyx, which is what is known as a biologic disease-modifying anti-rheumatic drug (DMARD). In April, however, CareSource, her insurance provider, stopped approving her prescription, leaving the Medicaid patient with a choice: go without or pay for the drug out of pocket. Depending on the treatment plan, Cosentyx injections can cost about $40,000 per year.
Maloney's battle is one being fought in doctor's offices across the state and country. Biologic DMARDs such as Consentyx, Rituxan and Rasuvo are hard to get approved by insurance companies. They're expensive, relatively new and not always on the preferred drug list, or formulary, of insurance companies and government programs like Medicaid.
Another CareSource patient, Cammie Dotson, a 37-year-old from Youngstown, has dermatomyositis. She has waited four months to get an approval for a new medication from CareSource. Her physician since June tried to get approval for three different medications and only in late October was able to get an appeal accepted for Rasuvo, an injectable form of methotrexate, a drug she was already on.
CareSource changed its appeals process in September, requiring physicians to get written consent from a patient before filing an appeal. But the Dayton-based insurer, which operates the state's largest Medicaid managed care plan, said 65 percent of its denials in 2017 were because physicians didn't properly verify "how the member met the policy criteria for the drug."
Dr. Ali Askari, division chief of rheumatology at University Hospitals and a professor of medicine at Case Western Reserve University School of Medicine said the patients are often the ones who suffer because of the delay.
"We see in front of our eyes: Some of these patients really deteriorate because they cannot get these medicines or they suffer from a lot of pain or discomfort," Askari said.
Of the more than 50 million people in the U.S. with some form of arthritis, an estimated 2.6 million live in Ohio, according to the Arthritis Foundation. Askari estimates 95 percent of rheumatologists rely on biologic DMARDs to treat patients.
Yet, the process for getting these medications is a long one. Biologic DMARDs require prior authorization, a process that differs by insurance company and means physicians need to submit requests to get medications approved. Prior authorizations then can be denied by insurance companies, requiring doctors to either file appeals if they want their patients to get the medication or prescribe a different drug.
"It depends on the plans people have. It's not always being denied," said Askari.
Physicians like Askari, who are part of large systems like UH, have less trouble dealing with insurers because they can rely on their staff's expertise in filing the complex prior authorizations and appeals, said Beth Moore, executive vice president of corporate communications for the National Patient Advocate Foundation.
"If you don't have coding and billing experts who stay abreast of the continuous changes that the insurers may make to the prior authorization process, you're more likely to run into snags," Moore said. "It sounds like this is just a restrictive prior authorization process that's been implemented by CareSource, and it's placing a burden on the providers."
Decisions about which prescriptions are approved involve which contracts insurance companies have with drug manufacturers, the medical justification given by doctors and the cost of the medication, Askari said.
For example, CareSource requires patients with psoriatic arthritis first fail trials of biologic DMARDs Enbrel and Humira before being prescribed Cosentyx.
"In some cases, members are required to use alternate medications as a first line of therapy for moderate to severe rheumatoid arthritis. If that treatment is determined inadequate, a more effective treatment is identified and prescribed," CareSource said in a statement.
This practice, known as step therapy or tiering, is one discouraged by the American College of Rheumatology (ACR).
"Step therapies, fail-first policies, tiering and class switching requirements often create unnecessary obstacles for patients and their physicians, delays in appropriate therapy, potentially dangerous outcomes for patients and can undermine careful and collaborative decisions made by patients and providers," ACR said.
Dr. Stephanie Ott, president of the Ohio Association of Rheumatology and a rheumatologist in Lancaster, said patients sometimes wait three to six months to get medications because of step therapy requirements.
"The patient is the one who gets turned down, and they're the ones suffering," Ott said....Read more