Dr. Ackerman on how step therapy requirements for OAB affect urologists


"Not only do we lose patients and we lose this opportunity to actually take good care of them, but it actually undermines their trust in us as a profession," says A. Lenore Ackerman, MD, PhD.

In this video, A. Lenore Ackerman, MD, PhD, highlights the effects of step therapy requirements for overactive bladder (OAB). Ackerman is a urologist at the University of California, Los Angeles Medical Center.

Video Transcript:

One of the ways it impacts us is that there is a need for an allocation of additional staff to just manage these medication requests, to follow up with patients to make sure that they were able to get the medication, and if they weren't, to initiate the prior authorizations or appeal decisions. That can be quite a substantial amount of effort or staff time to just doing that, which, of course, for a lot of practitioners, is completely uncompensated labor. As much as we'd love to be able to donate our time, we have to keep our offices running. If you have to spend every month devoting nearly a full-time person's week to doing these medication requests, you're probably going to be motivated to not do it, just in reality. So, you're going to give people those anticholinergics.

The sad thing is that with something like overactive bladder, we already have so many barriers to getting patients in to initiate care in the first place. They perceive that this is a normal part of aging, that there's nothing that they can do They're embarrassed to talk about it. They're embarrassed to tell you what's happened, or what's going on with their symptoms. They're embarrassed to tell you their constipation is terrible. There are all these preconceived ideas about overactive bladder that keep patients from coming in and being honest with us and really telling us the whole story. So, now, we send them home with something that maybe made their incontinence a little bit better, but now they can't poop at all, and so they just don't come back. There are plenty of data to show that your best time to catch somebody is that first visit. If you do something to them that makes them worse and makes them miserable, most of them will just stop the medicine and never come back.

From us as urologists, we're missing out on an opportunity to actually do the things we can do. We're not treating them with all those tools that we have. We're wasting money in our practices fighting with insurance companies, rather than just being like, "let's do some Botox and get you better.” And then, on top of all of that, as a clinician, there's this frustration [of] there are so many insurance plans, and even just within the Medicare system. The drug plans are so different from state to state, from person to person. There are so many variations that it's really hard for us to know what is and what isn't covered.

Not only do we lose patients and we lose this opportunity to actually take good care of them, but it actually undermines their trust in us as a profession when on the one, you could either give them an anticholinergic, they're going to have terrible [adverse events], and then they're going to not like you, or you try to go through this whole rigmarole of getting them the medication you'd prefer to get them, but then you have to give them this whole counseling about what's going to happen. Or you don't go through any of that, you try something, they go to the pharmacy, it's $200, and they just decide not to do it, but they don't want to come back because they don't want to disappoint you and say that they didn't take it. In all cases, everybody's losing.

This video has been edited for clarity.

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