Unfortunately, “step therapy” is a common practice in the insurance world. It requires patients to try out a cheaper, alternative prescription drug than the medication their physician originally prescribed. The hope is that the cheaper option will prove to be equivalent and effective. All too often, it’s not.
Only when – after considerable lost time – the proposed alternative proves ineffective; will insurers step up and pay for the originally prescribed medication.
It’s time to admit that step therapy, once touted as a way for insurers to save costs, simply doesn’t work. It generates miles of red tape, leads to higher patient costs, and in some cases, prevents people from getting any effective treatment at all.
I negotiate insurance contracts for physician offices, as step therapy rules, have become more onerous, many physicians have had to hire staff whose sole job is to manage drug therapy authorizations and appeals. What does that mean for the patient? Higher costs. Physicians must increase fees to cover their overhead costs. Ultimately, patients end up paying more money for potentially worse care.
Beyond seeing these costs professionally, I’ve known them personally. A few years ago, I opened the two letters from my insurance companies: “We are informing you that we have determined the drug that the patient is on has another drug option and we will no longer cover this medication effective January 1st. You can choose to continue the medication at your own expense or switch to our recommended drug.”
There were no appeal rights to this notification; it was switch or pay at my own expense.
I am a mother of children with Juvenile Idiopathic Arthritis, formally known as Juvenile Rheumatoid Arthritis. When these letters arrived, my daughter was on her eighth surgical procedure within five years. Her health was extremely fragile, yet the insurance company was forcing us to either gamble with her health by “trying out” their recommended medication or else take a huge financial hit ourselves by paying out of pocket for the medication her physician recommended. When the doctor’s office tried to call the insurance company to appeal this decision, they too were told there were no appeal rights.
Rheumatology patients rarely take one medication, rather, they take multiple medications at the same time. In my daughter’s case, trying out the medication the insurance company would cover to see if she failed on it, delayed other medication therapies because it would have been unsafe to have two new medications on board at the same time.
Ultimately, both of my children failed the insurance-recommended alternative, and were covered for the medication they were originally prescribed. But, I know there were costs to that delay both in her pain level and her medical stability.
Today, my daughter has already had one joint removed from one hand and this coming summer will have two more removed in her other hand, all before the age of 18 . And it’s not over yet: We have the constant concern that at any point we could receive future letters disallowing coverage for the medication recommended by her physician.
We need a solution.
Currently, before Texas Legislators are Senate Bill 680 and House Bill 1464, both of which address step therapy. These bills will ensure step therapy protocols are based on widely-accepted clinical guidelines so that medicine – not cost – dictate approval and coverage by insurers.
They will also help create a clear and efficient process to protect patients from being required to try or stay on a step therapy medication if it would create a significant barrier to adherence, worsen a comorbid condition, is contraindicated or will decrease the patient’s ability to achieve or maintain reasonable function. These bills must be passed not only for my family but yours.
McComb is a principal owner of Innovative Health Resources, a healthcare consulting company that represents hospitals and physicians in contract reimbursements with insurance companies.