Every day, 12.5 million Americans struggle with polycystic kidney disease, a disease that causes numerous cysts to grow in the kidneys, slowly reducing kidney functionality and possibly leading to kidney failure. I am one of them.
As the Memphis chapter founder and coordinator for the PKD Foundation, I work to help provide a forum for patients who want to find treatments and cure this disease.
That’s why I was alarmed by the Centers for Medicare and Medicaid Services’ new Medicare Advantage Part B step therapy policy, which would begin implementation next year.
Under step therapy, or “fail first,” health insurers require patients to use more cost-effective drugs before using more complex drugs, if the first drug doesn’t work. While this method may work for other parts of Medicare where generic and name brand drugs are indistinguishable, Medicare Part B drugs are not compatible with step therapy drugs.
Part B covers treatment for many serious conditions like PKD and relies on treatment that is tailored to the biology of each patient.
If health insurers forced doctors to prescribe less effective Part B treatments in the name of cost cutting, their zeal for cutting corners may backfire, leading to an increase in visits to the emergency room by Medicare Part B patients who respond poorly to the less effective treatment. As a result, the cost of treatment would rise exponentially, impacting the entire health care system and increasing costs for consumers.
This method also violates the trusted relationship between a doctor and patient. Doctors who treat patients with PKD often forge relationships with those patients that last years, forming a partnership to find the right combination of drugs that will allow each patient to manage their condition and retain a normal quality of life.
When an insurance company steps in on this years-long process in order to dictate which drugs it will allow, it throws years of hard work and collaboration out the window, jeopardizing both the doctor-patient relationship and the health of the patient.
This issue is incredibly personal for me. As someone who struggles with PKD, I anticipate undergoing a kidney transplant from a living donor in the next year. In order to make sure my body doesn’t reject the kidney, I’ll need to undergo a specific regimen of medications, tailored to my own body, for the rest of my life. I’ll be immunosuppressed, meaning I’ll be more susceptible to infections and certain types of cancer.
I can’t afford to “fail first,” or to gamble with drugs that an insurance company might choose for me based off of their own bottom line. This backwards approach takes away the rights of the doctor and the patient, and too often leads to increase in costs on the entire healthcare system.
Patients who battle PKD require timely care and should be permitted to opt out of step therapy, if their health or financial situations change. We simply can’t afford to try a cheaper, riskier treatment for a prolonged period with little success when there is an existing treatment that works. While health insurance companies want to pinch pennies, ultimately, we are the ones who may pay the price.
Sen. Lamar Alexander has been a champion for improving access to health care in this country. He understands that patients deserve to be taken seriously, and a doctor’s expertise should not be overrun by the will of an insurance company. That is why I urge Sen. Alexander to stand up for patients and doctors’ rights and reverse this harmful policy.
Karyn Waxman is the Memphis chapter founder and coordinator for the PKD Foundation.
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