These are strange times, when we have to think about insurance companies and medical equipment suppliers like they’re our doctors. No, of course they aren’t… But they’re acting like it, using strong-arm tactics couched in language like “preferred brand” to force specific products and treatments on patients despite doctors’ best advice.
Phrases like “therapeutically equivalent” are bantered about, despite the fact that in many cases, changing up meds and devices can jeopardize our health.
This is the world of Non-Medical Switching, where “payers” (health insurance companies) call the shots despite without necessarily listening to the medical advice of our healthcare professionals.
It’s nothing new. Those of us living with diabetes have faced these hurdles for years, sometimes more dramatically based on how much an insurer or pharmacy benefit manager (PBM) decides to dig their heels in. While we scream, “Prescriber Prevails!” because it should be up to us and our prescribing physician, the payers argue they’re respecting that but simply opting for a most-effective alternative.
What is new is a first-of-its-kind study released in February, showing that this practice of Non-Medical Switching can and does actually cause widespread damage to patients’ care and quality of life. This Alliance for Patient Access (AfPA) study found that of 800 people (27% with diabetes) surveyed in a national online poll late last year showed some alarming trends:
- 73% reported that NMS “disrupted” the plans they’d made with their prescribing physician
- 86% agreed that the insurer “took control” of a decision that “rightfully belongs” to the healthcare provider
- Roughly 40% said the new med wasn’t as effective as the original
- 60% experienced a complication of some sort as a result of the forced switch
- 40% who experienced Non-Medical Switching actually stopped taking their medications alltogether
So yes, this is more than an inconvenience — it’s a drain on quality of life, as well as economically.
The study also shows that two-thirds of respondents also said the forced switch impacted their productivity at work, while 40%+ said they weren’t able to care for their children, spouses or another family member as needed because of the switch.
Overall, Non-Medical Switching leaves people feeling: frustrated, confused, helpless, and anxious about losing access to the medications or supplies they need and have decided on, with their prescribers.
There’s quite a bit of advocacy on this issue nationally and specifically in the Diabetes Community, and we’re glad to know that it’s being addressed at the state legislative level. Personally, as someone who’s been hit by Non-Medical switching so many times over the years, it’s a topic that I care a lot about and am happy to be seeing addressed more broadly.
My Experiences with Forced Medical Switches
I’ve experienced this many times, and it’s an issue my medical care team and I are always frustrated with. Four examples come to mind, from recent years:
- CGM Type: Once at the start of a year with a new insurance company, I tried to refill
a Dexcom CGM sensor order and the company told me they wouldn’t
approve this CGM because I happened to use a Medtronic insulin pump – so
that brand “would be a better fit” for me. (Result: It took some serious insistence
with an insurance supervisor to make it clear that my doctor and I knew what was best,
especially given I’d been on Dexcom for years).
- Lantus to Tresiba: When
the new basal insulin Tresiba came out from Novo, I studied a lot of the data
and patient reported outcomes (PRO) that showed it might be better for me than
Sanofi’s Lantus. In particular, because Tresiba could last 42 hours
rather than the 24 of Lantus, so I may not have to split my total basal dose to twice-a-day to see the best effect. My insurance pushed back on this. Their argument: That Lantus
was “therapeutically equivalent” to Tresiba since they’re both basal insulins. So before they’d cover Tresiba, I’d have to show evidence that both Lantus and its competitor Levemir didn’t work for me after use for 30
days each. (Result: My
doctor and I reiterated that I’d been on Lantus for months, and that this
“step therapy” requirement had already been met – Lantus didn’t work as evidenced by my
higher A1C and glycemic variability, and if my insurer described Lantus as “therapeutically equivalent” to Levemir, then they couldn’t very well argue I’d
have to waste another 30 days trying that insulin. We ‘won’ after firing off an
appeal letter to the insurer.)
- Humalog to Novolog: Pretty
much the same situation as above, but this time I decided that it wasn’t worth
the fight to try for Humalog. I’d never actually tried Novolog before, and
despite reports out there about insulin differences and allergies, there was no
guarantee I’d experience problems. (Result: I opted to switch to Novolog pens
and in the end saw no difference. Turns out when reviewing the insurers’ Explanation of
Benefits, I could see there was hardly a difference in overall price tag between the two
brands – even though I’d be paying a $40 difference in co-pays!)
- Afrezza Inhaled Insulin: When my doctor and I later decided inhaled insulin would be
the best new treatment for me to try, we again had to hear about step therapy, and interestingly despite my past use
of Humalog and Novolog, my Afrezza still wasn’t initially approved. (Result: We wrote a
letter contending that we had met the step therapy requirements, and that Afrezza was
medically necessarily to prevent my severe hypos and glycemic variability. It
took two rounds of letters, but we once again prevailed.
Countless people with who live with diabetes and so many other health conditions experience this type of short-sighted cost cutting every day.
My endocrinologist has told me stories of other patients who simply don’t fight and accept whatever the preferred payer brand is — and then months later on a return office visit, my endo learns that they haven’t been using the new prescribed medication.
He has often wondered aloud, “Why bother having a medical license and even writing prescriptions, when they’re denied and second-guessed 99% of the time?”
I’d also argue it’s criminal, in that it equates to practicing medicine without a license. The individuals making these decisions may not even have an M.D. behind their name. Sure, there’s probably a doctor on the letterhead somewhere, but it’s often a nurse or even less trained insurance employee actually approving or denying insurance claims.
Of course, I’m a patient who’s aware that payers are in this for cost, and that you don’t have to take “No” for an answer — even when insurers, Pharmacy Benefit Managers, and third-party distributors try to force a change. That’s not the way it has to be. Patients have power and can fight back, sometimes with a little extra effort and at other times with more extensive appeals for coverage.
I also know I’m one of the lucky ones who has the resources to put up a fight.
I’m hopeful that national and state-specific advocacy and lobbying actions can move the needle, but in the meantime those of us on the patient and provider side are left dealing with these issues in the trenches.
I think both patients and healthcare professionals should be alarmed, and I’d encourage everyone to check out #KeepMyRx to learn more and take action. There’s also a webinar being hosted this week by the AfPA and the Diabetes Policy Collaborative (DPC) group. That’s being held at 3pm ET on Tuesday, March 12.
Let’s raise our voices and be part of the solution!