Opinion
Video
Impact of Step Therapy and Prior Authorization Requirements in Ophthalmology Practice
Joseph M. Coney, MD, FACS, explores strategies to address treatment obstacles among vulnerable patients and examines the effects of step therapy and prior authorization within a complex health care landscape.
Joseph M. Coney, MD, FACS: Step therapy has really impacted the way that I treat patients, particularly those who present to me with worse levels of visual acuity. We have several studies that show that individuals with a certain level of visual acuity typically don’t do as well on nonbranded medication, particularly when their visual acuity is 20/50 or worse. Unfortunately, the community that I see normally presents with a worse baseline visual acuity as well as worse baseline disease severity. Oftentimes I find myself using medications that are delaying their therapy by not giving them the most robust medicine approved for them. There has been a study that shows that by delaying this by 3 injections from off-label use to something on-brand, you really don’t have that much loss of vision. But I’ll tell you now, if patients don’t feel that they’re making progress in those first couple of months, sometimes they lose the follow-up. I really think it’s important early on for us to establish with our patients on a monthly basis that they are making some type of progress. This is a very tough population. These individuals already have a lot of anxiety just by being in the office. There’s a lot of misconception, mistrust, miscommunication, and a lot going on during these exams. I really think it’s important for us to have the ability to use whatever drug we have in our materials that we think may be beneficial to that patient.
Step therapy has been an issue. Another problem we’ve had is prior authorization. Prior authorization requires us to get approval before we’re able to give a patient a therapy, even if these medications are already approved. This is a population where transportation is already an issue, making it difficult for them to come to the office. Geographically, it may be very difficult for them to visit the office. Oftentimes, this population also serves as primary caregivers for their children, putting their needs before their own. Coming in for an injection in 2 weeks or another month may result in follow-up gaps or at least intervals where their visual acuity worsens. We need to have the ability to treat people the way they want to be treated and the way they need to be treated. Step therapy for this particular population poses a barrier and a burden to [these patients].
It’s important that all patients benefit from the advanced technology that we have in our office. And I believe it really comes down to a physician’s implicit bias. We should treat all people the same, regardless of their health care insurance, whether they have Medicaid, Medicare, or commercial insurance, regardless of their gender, race, or ethnicity. There are many trials that show that individuals with private insurance or Medicare tend to present to the eye doctor with better visual acuity when it comes to diabetes. Regardless of race and ethnicity, those with Medicaid tend to have worse vision at presentation. Disparities in health care exist, and I believe we owe it to our patients to provide them with the best treatment possible. This also requires that baseline exams need to be standardized. All individuals need to have the ability to receive the same evaluation and, hopefully, the same treatment so that the outcomes are consistent.
This transcript is AI generated and reviewed by an AJMC® editor.
