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Insurers Must No Longer Deny Access to Life-Saving Cardioprotective Medications

November 26, 2018

Studies have shown that more than 50 million Americans with health insurance have been denied essential treatments for chronic or persistent diseases, with two out of every three patients, like the woman we treated, being denied multiple times.

Every 40 seconds, someone has a heart attack or stroke in the United States. Those events put more than two million people in the hospital and are associated with more than 400,000 deaths among Americans every year.  Fortunately, the Centers for Disease Control and Prevention estimate that 80 percent of premature heart attacks and strokes are preventable.

Reducing the incidence of these potentially deadly medical events starts with eating a healthier diet and exercising more, but comprehensive treatment may also include a class of game-changing medications that can drastically reduce cholesterol levels in patients who are at risk for heart disease or stroke.  Yet despite the ability of these medications – called PCSK9 inhibitors – which can be used in conjunction with or as an alternative to statins to reduce cholesterol to previously unseen levels, insurers have often refused to cover the medications, claiming they were too expensive.

In an effort to help more patients have access to the latest treatments, one drug manufacturer has pledged to lower the list price of their PCSK9 inhibitor by 60 percent, which could save patients between $200 to $300 per prescription and make the treatments more affordable for both older adults on Medicare and other vulnerable Americans. It also means that insurers should no longer have a reason to override a provider’s orders and deny their customers access to evidence-based therapy.

Running a free cardiovascular risk reduction service at a local clinic has brought many polarizing insurance-related issues to the attention of both my colleagues and myself; I know first-hand how difficult it can be to get health insurer approval for the newest – and often most expensive – therapies for my patients.  For example, I treated a patient with a high risk of heart disease who needed a major reduction in her LDL cholesterol (LDL-C) ­– a.k.a. the “bad” cholesterol.  Her medical history included accumulation of plaque in her arteries, hereditary high cholesterol, type 2 diabetes mellitus, hypertension and a family history of premature heart disease.

In order to reduce her risk of heart disease, we started the patient on a four-week trial of a PCSK9 inhibitor with samples we had at the clinic. Her response to the PCSK9 inhibitor was remarkable; the patient’s LDL-C dropped 66 percent. Yet despite her tremendous response, the patient’s insurance company denied her access to the medication not once, but three times!  It was only after a fourth appeal – and somewhat bizarre peer-to-peer review process – that we were finally able to get approval of the medication for our patient.

Studies have shown that more than 50 million Americans with health insurance have been denied essential treatments for chronic or persistent diseases, with two out of every three patients, like the woman we treated, being denied multiple times.  It is extremely disheartening for practitioners like myself to have an insurer refuse to cover a medication for a patient that we know will reduce her chance of future heart-related complications (e.g., heart attack) – just because it is expensive.  Imagine you are a patient and at high risk for a heart attack; your insurance company has denied all requests for the potentially life-saving PCSK9 inhibitor your provider has prescribed because they don’t think the cost is worth it. Feeling defeated? Discouraged? For many patients, this is an unfortunate reality.

My primary concern is the health of my patients.  It is great to see a drug company reduce the cost of a potentially life-saving PCSK9 inhibitor, and I hope that other drug makers will continue to reduce the list price of their medications to make them available to more Americans.  I also urge insurers to take advantage of this decision to make critical treatments available to their patients who need them the most.

Author
Doctor of Pharmacy, Matthew Stryker, is a clinical pharmacist at Albany Medical Center and an assistant professor at Albany College of Pharmacy and Health Sciences with a focus on ambulatory care and endocrinology.
matthew.stryker@acphs.edu