Patient Access to Necessary and Appropriate Medical Care

By: 
American Association of Clinical Endocrinologists and American College of Endocrinology Address

There’s no question that healthcare is weighing heavily on the minds of Americans. In fact, a poll conducted in January by the Monmouth University Polling Institute revealed that a preponderance of U.S. citizens overwhelmingly placed healthcare costs above national security as their top concern. A recent Gallup poll reinforced these findings: 55 percent of respondents indicated they personally were worried about the availability and affordability of healthcare.

Between rising healthcare insurance premiums, increases in deductibles and out-of-pocket expenses, escalating costs of prescription medications and uncertainty regarding reforms to the Affordable Care Act (commonly known as Obamacare), everyone from individual consumers to small business owners to advocacy groups to major medical organizations are expressing their concerns.

Amidst this backdrop, the American Association of Clinical Endocrinologists and its education/scientific/charitable arm, the American College of Endocrinology, have issued a position statement advocating for patient access to medical care. The position statement is printed below in its entirety.

This document represents the official position of the American Association of Clinical Endocrinologists and the American College of Endocrinology. Position statements are meant to provide guidance, but they are not to be considered prescriptive for any individual patient and cannot replace the judgment of a clinician.

The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) envision a society in which all people in need, regardless of their disability, age, race, religion, ethnicity, gender, sexual orientation, or ability to pay, should have access to consistent, affordable, timely, patient-centered, comprehensive medical care. AACE/ACE support healthcare initiatives and efforts to increase the access and affordability of health insurance for everyone. Additionally, AACE/ACE support the following positions regarding medical care:

  • Individuals must be empowered to control and decide how their own healthcare dollars are spent;
  • Individuals must have unencumbered access to specialty care;
  • Healthcare coverage must be made more affordable;
  • There must be improved value and increased quality in our healthcare system;
  • Coverage and access should be extended to both the uninsured and under-insured;
  • Health care should be provided in a comprehensive, culturally and linguistically appropriate manner;
  • People of all ages and their families should have access to health care that responds to their needs over their lifetimes, and provides continuity of care that helps treat and prevent chronic conditions;
  • All individuals and their families should receive comprehensive health, rehabilitation, habilitation, and long-term support services provided on the basis of individual need, preference, and choice;

AACE/ACE oppose any policies that restrict access to medically necessary care and/or medications. Such policies, which include preferred drug lists with prior authorization requirements, restrictive formularies, fail-first requirements, monthly prescription limits, and tiered co-payment structures, fail to achieve their intended purpose of reducing overall healthcare costs. Such policies also prolong human suffering, and reduce the potential for an individual with a medical condition to make a full recovery. Moreover, restrictive policies fail to acknowledge that practitioners and patients should make individualized treatment decisions, recognizing the unique and non-interchangeable nature of human beings and medical care/medications. Restrictive policies also fail to acknowledge that the lack of access to necessary and appropriate medical care and medications has both human and fiscal consequences.

AACE/ACE believe that decisions should always be clinically based and that best practice treatment planning will provide long-term cost containment. If implemented based upon the evidence, the practices and tools identified above can be useful for policy makers, practitioners, and patients to ensure appropriate access to medical care and medications leading to quality improvement and cost containment

In this context, we wish to draw particular attention to insulin. Patients with type 1 diabetes need insulin for survival and frequently insulin is the only drug that can control the diabetes of patients with type 2 diabetes. In recent years, the cost of insulin has nearly tripled, which has placed tremendous hardship on many patients with diabetes, which may lead to poorly controlled diabetes when patients take less insulin than is prescribed, or even death in some cases.

Without adequate control of diabetes, people with diabetes have a higher risk of developing microvascular complications such as blindness, kidney disease and nerve damage, and macrovascular complications including heart attacks and strokes. Therefore, it is imperative that people who require insulin be able to obtain it at a cost that is affordable. AACE strongly encourages all parties involved in the production and distribution of insulin to make every effort to contain the cost of insulin.

Recognizing that many states have already implemented a preferred drug list, AACE/ACE support the exemption of all medications used to treat endocrine related conditions from prior authorization requirements. Such an exemption should address all classes of medications to treat endocrine diseases, and not include limits based on diagnosis. Moreover, states that have implemented preferred drug lists and other restrictive policies should ensure that the following consumer protection policies exist and are enforced:

  1. No "fail-first" requirements;
  2. Prescribers should have the option to designate “Dispense as Written” to prevent automatic switching at the pharmacy point-of-sale;
  3. A “grandfathering” policy should exist to ensure that consumers who are successfully being treated on a non-preferred medication are not forced to switch;
  4. Preferred drug lists should be developed and revised based on clinical evidence and scientific consensus taking into account efficacy, safety, and cost;
  5. Utilization management strategies should be developed by a Pharmacy & Therapeutics Committee that includes practicing physicians in the field of mental health and substance abuse treatment;
  6. The process for developing state utilization management strategies should include meaningful involvement from consumers and adequate opportunity for public input;
  7. Prior authorization should be timely and efficient so as not to delay access to medication, nor to deter the prescriber from ordering medications that will have optimal benefits;
  8. Appeals and grievance procedures must be clearly disseminated to beneficiaries (subject to restrictions) and must be both accessible and timely; and,
  9. Third-party payers should be legally accountable for harm to patients resulting from negligent utilization management policies or patient treatment decisions through all available means, including proportionate or comparative liability, depending on state liability rules.

References

AACE’s Position Statement on Patient Access to Necessary and Appropriate Medical Care are drawn from and reflect the significant background work of many organizations, particularly the American College of Physicians1, the American Academy of Dermatology Association2, Council of Medical Specialty Societies3 and, Mental Health America4.

  1. Stemming the Escalating Cost of Prescription Drugs: A Position Paper of the American College of Physicians, Hilary Daniel, BS, for the Health and Public Policy Committee of the American College of Physicians, published in the Annals of Internal Medicine, March 29, 2016.
  2. Position Statement on Patient Access to Affordable Treatments, American Academy of Dermatology Association, November 7, 2015.
  3. CMSS Principles for Increasing Access to Needed Medications by Patients, Council of Medical Specialty Societies, 2016.
  4. Position Statement 32: Access to Medications, Mental Health America, September 18, 2010.