ICER Report Could Intensify Barriers for Heart Patients

Accessing innovative cardiovascular drugs may soon get harder.

A new publication from the Institute for Clinical and Economic Review, a drug price analysis group, assigns a C+ effectiveness grade to cholesterol-lowering drugs known as PCSK9 inhibitors.  The lukewarm valuation sets the stage for increased health plan barriers, despite the drugs’ effectiveness in reducing heart attack and stroke risk.

PCSK9 inhibitors work by preventing the PCSK9 protein from destroying a receptor on the liver that clears bad cholesterol. The receptor “lives” longer, clearing more LDL cholesterol for the patient.  For some patients who don’t sufficiently respond to traditional statin therapy, the drugs have offered unprecedented improvement.

Read more at Institute for Patient Access. 

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Alabama Health Plans deny treatment for high cholesterol

The Institute for Patient Access released a new Health Plan Coverage Report Card claiming that Alabama insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors 53 percent of the time. The report card reveals that health plans reject more than one out of every two claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from August 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Alabama managed care organizations, including commercial plans, Medicare and managed Medicaid.

Read more at the Alabama Political Reporter

Cholesterol-Slashing Drug Can Protect High-Risk Heart Patients, Study Finds

The first rigorous test of an expensive new drug that radically lowers cholesterol levels found that it significantly reduced the chance that a high-risk patient would have a heart attack or stroke. These were men and women who had exhausted all other options.

The results of the study, which cost about $1 billion and was paid for by Amgen, maker of the drug, were published on Friday in The New England Journal of Medicine and presented at the annual meeting of the American College of Cardiology.

Read more at The New York Times. 

***PRESS RELEASE*** Texas Health Plans Reject Nearly Half of Claims for High Cholesterol Treatment

New health plan report card analyzes PCSK9 inhibitor claims for managed care organizations

 WASHINGTON – The Institute for Patient Access released a new Health Plan Coverage Report Card highlighting the rates at which Texas insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly one out of every two claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from July 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Texas managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key Texas Findings:

• 46% average rejection rate
• 2,877 total rejections
• 745 appeals
• Highest rates of rejection: Federal Employee Benefit Plan (91%), Express Scripts (73%), Teacher Retirement System of Texas TRS (64%)
• Lowest rates of rejection: Humana Health Plan (31%), Tricare Military Health SVC SYS (31%), Aetna US Healthcare (28%)

View the full Report Card

“This is a very troubling and frankly dangerous finding,” said Alliance for Patient Access Executive Director Brian Kennedy. “The patients prescribed this medicine have extremely high LDL cholesterol, and statins alone are not sufficient to reduce their risk of heart attack. With these new cholesterol-lowering drugs, patients’ risk of heart attack decreases, yet insurance companies are too often refusing to cover the medicine.”

PCSK9 inhibitors work by extending the lifespan of a receptor on the liver that clears “bad” cholesterol.  Clinical trials data show that PCSK9 inhibitors can lower LDL cholesterol more than statins alone and can also reduce the associated risks of heart attack and stroke.

The Institute for Patient Access report card highlights the 13 Texas health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were the Federal Employee Benefit Plan, with a rejection rate of 91%, and Express Scripts at 73%. Also denying claims at a far higher rate than the state average were Teacher Retirement System of Texas TRS, 64%, and Wellcare Management Group, 61%. Humana Health Plan, Tricare Military Health SVC SYS and Aetna had the lowest rejection rates, though they still denied roughly 30% of claims.

This report card is one in a series to be released by the Institute for Patient Access in 2017 to highlight barriers to patient access.

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BACKGROUND

Institute for Patient Access

PCSK9 Inhibitors Texas Report Card

Alliance for Patient Access

New Collaboration Improves Access to Treatment for Familial Hypercholesteremia (FH) Patients Most at Risk for Early Heart Attacks and Death

PASADENA, Calif., March 15, 2017 /PRNewswire-USNewswire/ -- The FH Foundation, a patient-centered non-profit dedicated to research, advocacy, and education of all forms of familial hypercholesterolemia (FH), today announced its collaboration with Express Scripts, a leading pharmacy benefit manager, to improve pharmacy coverage for patients with FH, an inherited genetic disorder that causes high LDL-cholesterol from birth. With a more comprehensive set of diagnostic criteria, a broader group of patients will have access to cutting-edge PCSK9 inhibitor treatment, as appropriate.

Read more at PRNewswire. 

Dr. Keith Ferdinand: Together, We Can Save Hearts

Good health is the cornerstone of progress, and since 1974, the Association of Black Cardiologists (ABC) has been dedicated to lowering the high rate of cardiovascular disease, including stroke, especially in minority populations.  As an ABC member and Chairman of the ABC Access to Healthcare Working Group, I have spent my career pursuing a central goal of ABC—to eliminate the disparities related to cardiovascular disease in all people regardless of race, ethnicity, gender, geography, or socioeconomic status.

Read more at The New Orleans Tribune. 

Report: Florida HMOs slammed for denying cholesterol drugs

Florida health plans on average reject 45 percent of the claims claims submitted for coverage of prescribed advanced cholesterol lowering drugs, according to the advocacy group known as Institute for Patient Access.

The institute released a report card highlighting the rates at which Florida insurers deny patients coverage for the medications, known as PCSK9 inhibitors.

More at Politico. 

***PRESS RELEASE*** Florida Health Plans Reject Nearly Half of Claims for High Cholesterol Treatment

New health plan report card analyzes PCSK9 inhibitor claims for managed care organizations.

WASHINGTON – The Institute for Patient Access today released a new Health Plan Coverage Report Card highlighting the rates at which Florida insurers deny patients coverage for advanced cholesterol-lowering drugs known as PCSK9 inhibitors. The report card reveals that health plans reject nearly one out of every two claims submitted for coverage of prescribed PCSK9 inhibitors. The data, collected from August 2015 to July 2016 by a national data supplier, reflects PCSK9 inhibitor claims for Florida managed care organizations, including commercial plans, Medicare and managed Medicaid.

Key Florida Findings:

• 45% average rejection rate
• 3,784 total rejections
• 1,197 appeals
• Highest rates of rejection: Federal Employee Benefit Plan (77%), Express Scripts (76%), Cigna Healthcare (63%)
• Lowest rates of rejection: Aetna US Healthcare (29%), Freedom Health FL (29%), Humana Health Plan (29%)

“This is a very troubling and frankly dangerous finding,” said Alliance for Patient Access Executive Director Brian Kennedy. “The patients prescribed this medicine have extremely high LDL cholesterol, and statins alone are not sufficient to reduce their risk of heart attack. With these new cholesterol-lowering drugs, patients’ risk of heart attack decreases, yet insurance companies are too often refusing to cover the medicine.”

PCSK9 inhibitors work by extending the lifespan of a receptor on the liver that clears “bad” cholesterol.  Clinical trials data show that PCSK9 inhibitors can lower LDL cholesterol more than statins alone and can also reduce the associated risks of heart attack and stroke.

The Institute for Patient Access report card highlights the 15 Florida health plans that process the most PCSK9 inhibitor claims, ranking them based on the number of rejections issued. The least patient-friendly plans were the Federal Employee Benefit Plan, with a rejection rate of 77%, and Express Scripts at 76%. Also denying claims at a far higher rate than the state average were Cigna Healthcare, 63%, and Florida Blue, 61%. Humana Health Plan, Aetna and Freedom Health Florida denied fewer than 30% of claims.

This is the first in a series of state report cards that the Institute for Patient Access will release in 2017 to highlight barriers to access.

“Accessing Cholesterol Treatments” is No Simple Task, Explains New Video

On the heels of recent research confirming breakthrough drugs’ impact on patients with high cholesterol, the Partnership to Advance Cardiovascular Health has released a quick-draw videoexploring obstacles for patient access.

In “Accessing Cholesterol Treatments,” narrator and cardiologist Seth Baum, MD, describes a hypothetical patient with a family history of extremely high cholesterol. “He’s not the typical cholesterol patients,” Dr. Baum explains, “And the typical medications, known as ‘statins,’ don’t lower his cholesterol enough.”

More at Institute for Patient Access

Will New Evidence on PCSK9 Inhibitors Improve Patient Access?

For patients with extremely high cholesterol, the promise of new PCSK9 inhibitors just keeps growing. Data presented at this month’s American Heart Association meeting confirms that the breakthrough drugs lower LDL cholesterol – as anticipated. But it also reveals that the treatments can reduce the buildup of heart attack-causing plaque on the walls of coronary arteries.

Now the study’s results beg the question: Will new evidence of PCSK9 inhibitors’ impact lead to improved health plan coverage?

More at Institute for Patient Access

Cholesterol Drug Shows Promise to Help Reverse Heart Disease

For the first time, a new drug given along with a cholesterol-lowering statin medicine has proved able to shrink plaque that is clogging arteries, potentially giving a way to undo some of the damage of heart disease.

The difference was very small but doctors hope it will grow with longer treatment, and any reversal or stabilization of disease would be a win for patients and a long-sought goal.

More at US News & World Report

The PCSK9 Inhibitor Conundrum

Medicine is at a crossroads; cardiology in particular. I saw this fact magnified at the American Society for Preventive Cardiology’s recent town hallon access barriers to PCSK9 inhibitors. The event was entitled, “Unraveling a Therapeutic Conundrum,” and the conundrum is this: Will we embrace the potential that these innovative drugs hold for patients, or will we use them as a scapegoat for soaring health care costs?

A guest blog by Seth Baum, MD, at Institute for Patient Access

A $14,000 Price Tag For A Cholesterol Drug Can Be A Bargain

Drug pricing has emerged as a major concern across the country and is even beginning to factor into the United States presidential race.

More at Forbes

New Data Spark Debate on Cost and Value of Breakthrough Cholesterol Meds

A new analysis calls for drastic price reductions for PCSK9 inhibitors, breakthrough lipid-lowering medications. Data published in the Journal of the American Medical Association suggest that the treatments would need to be reduced to two-thirds their current price to meet analysts’ cost-effectiveness thresholds.

But critics say the analysis drastically overestimates the number of patients who receive the treatment – and overlooks the individual value of these treatments for patients whose high cholesterol is not adequately controlled by traditional statins.

More at Institute for Patient Access

As Heart Disease Plagues the Black Community, America’s Access to Medicines May Be Headed for Crisis

Heart disease is the longstanding No. 1 killer of Americans, and the leading cause of death among Marylanders. While this silent killer devastates populations of all racial and ethnic groups, African-Americans are at the highest risk – deaths from heart disease among African Americans are 30 percent higher when compared to the White population.

Many African-Americans are all too familiar with family members who have struggled with this disease and have witnessed firsthand the devastating effects from physical to psychological to financial. With new breakthroughs in life-saving medicines, why does this death toll remain so high? Access continues to be a defining problem for doctors and their patients.

Read more at Orlando Advocate