Difficulties exist between neurologists and insurance companies in regards to multiple sclerosis treatment.
The FDA currently has 13 disease-modifying therapies (DMTs) registered for patients with multiple sclerosis (MS). These medications are not interchangeable, so selecting the best treatment option requires shared decision-making between patients and neurologists.
However, according to a study published in Neurology Clinical Practice, many insurance companies restrict access to MS DMTs through tiered coverage and various regulations in order to reduce costs.
In the study, researchers discuss a patient who started weekly injections of interferon-β-1a (IFN-β-1a) IM, and due to her phobia of needles, her husband needed to administer the treatment. Over the next few years, the patient and her neurologist attempted to find a new treatment due to her clinical relapse, despite her treatment with interferon.
Unfortunately for this patient, after finding a treatment that would not worsen comorbidities and had known long term risks, this patient’s insurance company denied coverage of the drug they chose, dimethyl fumerate, on the grounds that this patient did not have a failed trial of glatiramer acetate.
The neurologist had to then write an appeal letter explaining the patient’s inability to perform self-injections. However, after further delays, the patient qualified for a program where she obtained the drug at no cost and now has excellent control of her MS, according to the study.
The authors said that there is an increase of patient compliance and health outcomes when patients and physicians share decision-making.
Due to the complex nature of MS and the ranging severity, decisions about MS DMTs are also complex, with factors such as attitudes about their MS, lifestyle, and risks and benefits of each therapy need to be explored prior to prescribing a treatment.
According to the study, shared decision-making between MS patients and their neurologists can ensure the patient will receive a treatment that will control their MS and meet their goals and preferences.
Though the shared decision-making process is complicated, insurance companies that act through pharmacy benefit managers (PBMs) can limit treatment options.
Due to the average cost of $60,000 to $75,000 per year for these treatments, PBMs try to limit the costs through establishing tiers of which therapies they will cover.
The study authors wrote that these companies can potentially deny coverage of certain treatments with potentially little or no input from neurologists.
Researchers also wrote that a lack of meaningful dialogue between these groups can cause PBMs to deny coverage for needed treatment.
Step therapy can be illogical due to many drugs being tried before insurance companies will approve the use of an oral drug.
According to the study, major obstacles that exist between neurologists and decision makers include lack of reply to appeal letters, phone trees, and time needed to contact different insurance companies for different patients.
Also, delaying treatment could possibly harm MS patients since treatment is the most effective when started earlier rather than later. Trying different ineffective medications could potentially result in poor disease control and permanent loss of function.
In order to remedy the situation, researchers believe there are 3 main ways neurologists can change this situation.
First, neurologists must acknowledge that controlling costs is a legitimate concern, however, insurance companies should include neurologists and MS patients to establish proper policies that are no longer rigid and take disease severity and patient preference into account. Timely and efficient coverage should also be offered by these companies to avoid long-term harm for patients.
According to the study, neurologist associations and patient advocacy groups need to lobby for state and federal legislation for fair access to MS DMT.
Neurologists also need to advocate for lower MS drug costs since the cost of treatment has risen over the last few years without explanations, the authors noted.
Researchers conclude that individualized and ethical treatment can only be possible with the cooperation of insurance companies.