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How Access Barriers Impact Treatment Outcomes

Eli Lilly and Company  | July 29, 2019

Tags |  Immunology, Policy

This guest article comes from Natalie Boytsov, Ph.D., health economist and research advisor at Lilly. 

Thanks to the incredible achievements in scientific discovery of the past few decades, people with serious, chronic autoimmune diseases now have more treatment options to help them live healthier, more productive lives. As our health care system and treatment paradigms continue to evolve, health plans have responded by implementing policies to contain their spending on prescription medicines. 

For example, step therapy is a practice that requires people to first try and fail with a health plan’s preferred treatment before they can gain access to other medicines – even if the newer medicine was the one their health care provider prescribed first.   

Lilly believes it is critical to assess these kinds of practices to determine what exactly their consequences may be. In partnership with IBM Watson Health, we recently conducted a new study published in PharmacoEconomics that focuses on how step therapy affects treatment outcomes for people with rheumatoid or psoriatic arthritis. 

First of all, the study confirmed that step therapy is common. The study looked at the treatment outcomes of 3,993 people with rheumatoid arthritis (RA) and 1,713 people with psoriatic arthritis (PsA) whose coverage was managed by 25 different insurance plans: Access to at least one biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) was restricted for more than a third of these people. Among the people with access restrictions, 70% of people with RA and 79% of people with PsA were in plans that required step therapy with or without prior authorization (PA), versus plans that required just PA. 

Second, and of greater concern, are the study’s findings on how step therapy negatively impacts treatment effectiveness and medication adherence among people with RA and PsA. The data show that people with RA whose insurance plans required this fail-first approach to biologic or targeted synthetic DMARDs had 17% lower odds of treatment effectiveness compared to people who did not have access restrictions. The study also found that medication adherence was 18% lower for people with RA whose plans included step therapy requirements, compared to people who did not have access restrictions. 

These patterns were similar among people with PsA: the odds of medication adherence were 27% lower, and the likelihood of treatment effectiveness was 25% lower, among people whose insurance plans had step therapy versus people who did not have access restrictions. 

One of the key findings is that step therapy, which is often used to contain costs, may actually lead to additional health care use over an individual’s coverage period. For example, people with RA whose plans restricted their access to medicines were three times as likely to be admitted to the hospital because of an infection, and almost twice as likely to visit the emergency room during the study period. Additionally, more people with access restrictions filled prescriptions for glucocorticoids and non-steroidal anti-inflammatories than patients without access restrictions, which could be an indication of poorly managed disease. The pattern was similar among people with PsA as well. 

Our aim in supporting this research is to help educate payers and people with rheumatic diseases about the consequences of step therapy. We also see potential implications for the management of benefits plans. For many people with RA and PsA, the journey of finding an effective treatment can be long, with many physical and emotional ups and downs. Lilly believes there is an opportunity for the health care system’s key stakeholders to explore legislation and incentives that ensure people have open access to the treatments they need.