Priority Health, BCBS, others receive failing grades

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A recent Emory University study scored Michigan private and public health plans based on access to medicine coverage for patients with five autoimmune diseases.

Let MI Doctors Decide, an initiative of the Eastpointe-based American Autoimmune Related Diseases Association and the group that commissioned the study, then used the scores to “grade” health plans and their medicine access practices for the individual diseases: Crohn’s disease, multiple sclerosis, psoriasis, psoriatic arthritis and rheumatoid arthritis.

None of Michigan’s top 25 health plans received overall grades above a C.

The most widely used plan, Blue Cross Blue Shield of Michigan PPO 3 Tier, which covers nearly 844,000 people, received a C.

Grand Rapids-based Priority Health Michigan PPO, the state’s fourth-largest plan with more than 231,000 people, received an F.

Other plans to receive an F include Health Alliance Plan Michigan PPO Three Tier, Blue Care Network of Michigan FEHBP, SilverScript Choice, BCBS Michigan PPO 5 Tier and Priority Medicare Value.

Considering several key findings, the study noted people living with autoimmune diseases in Michigan face “substantial hurdles” to accessing necessary medicine due to “restrictions” imposed by health plans.

This primarily is due to the specific form of prior authorization known as step therapy, also known as “fail first,” according to Virginia Ladd, executive director of AARDA.

Let MI Doctors Decide stands against step therapy, which the study describes as a “cost-constraining measure” used in illness treatment that requires patients to first try one or more older, typically lower-cost, often generic drugs — and prove them ineffective or insufficient — before higher-cost, typically newer, brand-name drugs will be covered.

That means even if a doctor determines a higher-tiered medication is needed, the patient would need to go through the step therapy process required by the patient’s health plan.

This process of stepping from one medication to the next can take months, Ladd said, time people with serious diseases need for proper treatment.

She said autoimmune diseases range in seriousness; some cases are treatable with mild medication, and some cases can cause irreversible organ damage if not treated in time.

She called the step therapy practice “cost-centered,” not patient-centered.

A survey of 600 doctors published last month by Washington, D.C.-based Aimed Alliance, an organization focused on rights of health care consumers and providers, found 90 percent of doctors criticize step therapy, and 91 percent say prior authorization practices delay needed care.

The doctors in these autoimmune specialties are experts and should have the final say, Ladd said, yet people with less experience or understanding of the patients’ records are making decisions about which medicines are covered.

“A physician usually tries to use the treatment that's going to work the best, not overtreatment,” Ladd said. “You don't (immediately) use a hammer for attack, but if you need a hammer, then you have to go right to it.”

An auto insurer would not require a customer to receive work from a low-rated mechanic before pursuing the best option, she added, saying health care should be the same.

With data from Managed Markets Insights and Technology, the study evaluated each plan’s access to the medicines used for each condition, assigning scores using a point system based on formulary status, tier placement, prior authorization requirements and step therapy requirements.

One point was assigned if the plan had any step therapy requirement and another point for a prior authorization restriction. Points also were assigned based on where a drug appeared on a plan’s formulary, which dictates patient out-of-pocket costs.

On a scale from 0 to 4, lower scores indicate the fewest restrictions, while the highest scores indicate multiple restrictions.

Let MI Doctors Decide assigned grades to those scores and gave overall grades based on the averages of each plan’s five condition-specific scores: an A for one point or less; B for greater than one, up to two points; C for greater than two, up to three points; and F for greater than three points.

Of the individual disease treatments analyzed, patients with psoriatic arthritis and rheumatoid arthritis appear to face the toughest restrictions, with 10 of the plans in the top 25 receiving failing grades. Patients with Crohn’s disease and psoriasis also face a high number of restrictions, with almost one-third of plans in the top 25 receiving failing grades.

Medicare plans have tougher restrictions for the individual diseases than private insurers, with SilverScript Choice and Priority Medicare Value receiving failing grades for all five conditions and Express Scripts EGWP High Performance 3 Tier receiving a C for Crohn’s and a B for MS.

The study also found plans covering federal employees imposed greater access restrictions than other private and public employers in Michigan for all five autoimmune diseases. The federal employee plans Blue Care Network of Michigan FEHBP and BCBS FEP Standard each received an F.

The study showed the largest private plans tended to allow better access than others, though coverage offered by private employers with fewer people covered achieved the best scores for access.

Dow Corning, General Motors, Memorial Healthcare, and Genesee, Calhoun, Newaygo and Sanilac counties each received overall B grades.

Blue Cross Blue Shield of Michigan and Priority Health declined interviews with the Business Journal on the matter but sent statements via email.

Atheer Kaddis, vice president of pharmacy services at Blue Cross Blue Shield of Michigan, said: “Blue Cross Blue Shield of Michigan is committed to ensuring our members have convenient access to safe, cost-effective medications when they need them, while also maintaining the responsibility to our customers to ensure effective treatment is provided, and dollars are spent on evidence-based treatment.

“Our pharmacists do this in many different ways, including our therapeutics review committee and, at times, the use of prior authorization and step therapy. Step therapy and prior authorization are pathways to coverage for our members. They enable health plans to take responsible steps to support evidence-based medicine so that health plan members get the most appropriate and effective care.”

Christina Barrington, Priority Health vice president of pharmacy programs, said: “The most expensive treatment isn’t always necessarily the best treatment. Step therapy is a well-established strategy, used by many insurers, to help their members find the most effective treatment option, while also managing health care costs. By using step therapy, we can work with our members to determine if there is a lower-cost option available that offers the same benefit as the most expensive specialty or name brand drug.”

Barrington and Kaddis each have pharmacy doctorate degrees. Both companies staff physicians as chief medical officers.

Ladd said an increasing number of patients were reporting to the AARDA of trouble accessing needed medications, which she said primarily is because of step therapy, so the study was commissioned to help patients better understand health plan practices when enrolling.

“I wouldn't think they would want to go with a company that got an F,” she said, “because, probably, they would have access problems.”

The study cited mixed evidence on how prior authorization and step therapy affects overall cost and health. While some studies have shown these methods can reduce initial costs, the study cited others that questioned whether the practice was beneficial for long-term health, therefore long-term costs.

A 2008 study by the University of North Carolina at Chapel Hill, for example, found step therapy for schizophrenia medications reduced costs for Georgia Medicaid by $20 per month but raised outpatient services costs by $32 per month.

Ladd said many people can live for more than 30 years with autoimmune diseases, and if they suffer enough organ damage to need a transplant, that can cost insurance companies more long term.

You have to have health insurance, but it doesn't do you a lot of good to have health insurance if you can’t access the treatment,” Ladd said.

She also said the issue can lead to a breakdown in doctor-patient relationships because patients often do not understand how the system works, only that they keep switching medications.

The Aimed Alliance survey also found 89 percent of doctors feel they no longer have adequate influence in making health decisions, and 47 percent worry patients are losing confidence in the care physicians provide.

Ninety percent of the respondents also said they have significantly diminished time for patient care because of time-consuming prior authorization paperwork, and 77 percent had to hire extra staff to help with the increased administrative burden.

Ladd said she would like to have a discussion with insurance companies and all other health care players about these issues.

“I think they could solve the problem to the benefit of all, and that's what our goal would be,” Ladd said.

She said the two insurance companies’ decisions to decline interviews with the Business Journal may be a bad sign regarding future discussion, but she said she remains hopeful.

Health plan

   Enrollees 

 Average   score

      Grade 

Blue Cross Blue Shield of Michigan PPO843,8902.24C
3 Tier Express Scripts National Preferred with Advantage Plus288,2692.36C
Express Scripts National Preferred with Advantage235,1882.35C
Priority Health Michigan PPO231,1003.63F
UAW Retiree Medical Benefit Trust228,3222.57C
Express Scripts EGWP High Performance 3 Tier200,4652.92C
UnitedHealthCare Advantage 3 Tier PPO163,5942.44C
Department of Veterans Affairs150,0552.72C
Health Alliance Plan Michigan PPO Three Tier128,8773.16F
Blue Care Network of Michigan FEHBP126,1363.50F
CHE Trinity Health Employees 124,7222.82C
University of Michigan108,5132.73C
Chrysler Group LLC104,7672.86C
BCN Blue Essentials88,0042.03C
Blue Care Network of Michigan HMO 3 Tier88,0042.47C
State of Michigan Employees87,5742.47C
SilverScript Choice93,5303.76F
CVS Caremark Performance Standard Control w/ Exclusions & Adv Specialty Control82,7292.82C
BCBS Michigan PPO 5 Tier77,4223.54F
BCBS MI PPO 2 Tier Clinical77,4222.03 C
BCBS Michigan PPO 2 Tier Closed77,4222.59C
OptumRx Premium Highly Managed with UM76,5632.65C
TRICARE East74,6692.44C
UnitedHealthCare Traditional 3 Tier PPO71,9192.42C
Priority Medicare Value 75,5873.72F

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