Dr Christopher Phillips on the Insurance Challenges in Rheumatology

Christopher Phillips, MD, a rheumatologist in Kentucky, discusses some of the insurance challenges for patients confronted by prior authorization and the possible impact on their disease and quality of life.

Transcript

What are some of the quality of life issues for patients with rheumatological diseases who are cycling through different treatments based on insurance issues?

That depends on the disease state; so frequently, you know, joint inflammation is a frequent manifestation of some of our diseases. Obviously, inflamed joints lead to functional disability, work absenteeism, inability to just carry out basic activities of daily living, or even, you know, when that can be done, struggles to do it—morning stiffness, prominent fatigue, just not having the energy to do things that's so common in patients who you know have unchecked inflammation, which is often part of these diseases. Some of them, like uveitis, can be sight threatening and so, these patients are threatened with losing vision or vasculitis can target organs like the kidneys and the lungs. Patients are threatened with dialysis or with being on ventilators.

So, there's so many different manifestations and some of them are function-threatening, some of them are life-threatening. And for some of them, you know, the window of time that it takes to get patients on an effective treatment is critical. And so, with many of these rare diseases, even if we're fortunate enough to procure access to treatment, it may take weeks and even sometimes months to do so. And those can be very dicey periods, depending on the disease. And that may lead to need for treatment with high doses of steroids, which carry their own problems and toxicities and immune suppression and so on.

In terms of patient outcomes of prior authorization, are you saying it could lead to more severe disease later on if the condition goes untreated?

I think there's data to support that. I think that ACR [American College of Rheumatology] has some citations as far as surveys that have been done with physicians regarding the typical amount of time it takes to get prior authorizations approved. And I think in one survey, at least a quarter of physicians reported having had patients suffer significant disability or harm from prior authorization.

You know, a 1- to 2-day turnaround is short. And a several week turnaround is not uncommon. And when you kind of merge together the issues of prior authorization with step therapy—you know, the prior authorization process—it may take several weeks for you only to learn that, you know, the treatment is going to be denied, because there's a step therapy protocol and the payer wants the patient to take this other treatment first, which may or may not be a reasonable treatment for that patient, depending upon their medical comorbidities.