Step therapy: A policy out of step with patient needs

From newspapers and television news to social media and talk radio, healthcare often dominates the national discussion, particularly the cost of care. Not as frequently mentioned, however, are the barriers patients face when they access the healthcare system, particularly the cost of their prescription drugs.

When I served in Congress, including as vice chairman of the principal House panel with jurisdiction over healthcare policy, my top priority was ensuring patients could access the lifesaving therapies they needed. To me, this wasn’t abstract policy. It was personal.

{mosads}When my mother was first diagnosed with a blood cancer, she was given two years to live. That she lived for six years was a testament not only to my mom’s spirit and will to live but also to the extraordinary medicines she received.

But too often patients who need access to today’s miracle treatments face unnecessary barriers as they try to navigate insurance companies’ “step therapy” and “specialty tier” requirements.

What are these requirements? Insurers designed step therapy to encourage physicians and patients when medically appropriate to first try less-expensive drugs before prescribing high-cost drugs.

Insurers reasonably used step therapy when there were two innovator drugs on the market and one went generic. The insurance company would require the patient to “step through” the cheaper generic product before trying the more expensive innovator product.

On its face, step therapy seems like a reasonable policy, particularly when it’s targeted to a single innovator drug and a generic. When used properly and within the right disease and drug classes, and with the right patients, step therapy can be an appropriate and effective cost saving tool for both patients and the healthcare system.

But that’s not what is happening today. Insurance companies are applying step therapy and specialty tiers broadly – and in so doing, restricting physicians’ discretion and interfering with the practice of medicine.

This forces doctors to begin treatment with a drug just because it’s on the insurance company’s “preferred” list. Only when this medicine is deemed ineffective will the insurer cover the “non-preferred” drug that the doctor wanted to prescribe all along.

Today, patients and even physicians themselves spend weeks or even months making phone calls and submitting paperwork to insurance companies just to allow doctors to prescribe the medicine they believe is best suited to their patients.

This needs to change. Requiring patients to first fail on one medication before they can gain access to the treatment their physician believed was the most appropriate is simply wrong.

Independent studies of the impact of step therapy have shown they reduce use of new medicines but increase total medical spending because people wind up getting sicker. Step therapy can even expose patients, especially children, to less safe drugs, including those that have black box warnings from the FDA.

There shouldn’t be artificial barriers between doctors and their patients. But too often today, step therapy – and the insurance companies behind these policies – acts as a traffic cop between doctors and their patients.

This week, the American Autoimmune Related Diseases Association hosted the first congressional briefing on step therapy and access issues for autoimmune patients. This was an important opportunity to give policymakers on Capitol Hill visibility into the impact on patients, the burden on physicians, and the added costs to the system when insurers’ utilization management practices like step therapy go bad.

It is my hope that this is the start of a real discussion on what we can all do to improve the lives of patients in the autoimmune community and beyond. We have an opportunity to improve outcomes, save costs, and continue the incredible path of medical innovation.

Ferguson served in the House from 2001-2009. He currently heads the government affairs firm Ferguson Strategies, LLC. 

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