Instead of ‘Fail First,’ put patients first
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Although it’s commonly accepted logic that the shortest distance between two points is a straight line, many health insurers seem to disagree.

In fact, when it comes to covering essential treatments for patients suffering from debilitating conditions, the distance between the prescriber’s pen and the goal therapy is often a long, circuitous, and painful journey – one that does neither patients nor the health care system any favors.

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Step therapy – also known as “fail first” – is a troubling practice employed by many insurers that forces patients to try lower-cost therapies before being approved for more expensive treatments – even when doctors are certain that the cheaper option won’t be effective. Utilized by both public and private insurers, step therapy undermines the clinical judgment of health care providers and puts patients’ health at unnecessary risk.

Unfortunately, the millions of Americans living with rheumatic diseases have learned about step therapy the hard way.

Rheumatic diseases are autoimmune and inflammatory conditions that can cause a patient’s own immune system to attack the body’s joints, muscles, bones and other organs. Difficult to diagnose (and frequently misdiagnosed), rheumatic diseases in their mildest forms can cause discomfort and some difficulty with everyday tasks. But in many cases, if not treated promptly with the appropriate medications, these diseases cause severe pain, swelling, joint deformity, and long-term disability.

In fact, arthritis and other rheumatologic conditions are the country’s leading cause of disability – generating more than $303 billion in annual health and indirect costs, according to the latest estimates from the Centers for Disease Control and Prevention.

The systemic nature of inflammatory rheumatic diseases means they can affect other organs in the body, increasing the risk of serious and life-threatening conditions such as heart attack, stroke, lymphoma, cancer, lung and kidney disease. Untreated or inadequately treated inflammatory rheumatic diseases may also shorten life expectancy.

Fortunately for the one in four adults who have been diagnosed with arthritis, effective treatments – like next-generation biologic and biosimilar therapies – do exist. But treatments for rheumatic conditions are not one-size-fits-all, and must be carefully tailored to a patient’s individualized conditions and needs. 

So, when insurers deny coverage of a treatment based on the “step therapy” approach, patients can suffer greatly. It’s more than a matter of trying and discarding treatment regimens to find one that works, with hopefully the cheapest price tag; undergoing useless therapies can be as dangerous and costly as it is inefficient.

A survey of more than 1,400 patients conducted in July-August 2016 by the Arthritis Foundation revealed that over half of all patients reported having to try two or more different drugs prior to getting the one their doctor had originally ordered. Step therapy was stopped in 39 percent of cases because the drugs were ineffective, and 20 percent of the time due to worsening conditions. Incredibly, nearly a quarter of patients who switched insurance providers were required to repeat step therapy with their new carrier.

For many, step therapy compounds an already challenging condition. Fifty seven percent of patients surveyed by the Arthritis Foundation reported requiring additional medications for pain, depression, or anxiety as a result of undergoing an ineffective treatment process. Forty percent developed new joint damage, and more than ten percent had to be hospitalized or required surgery. 

Thankfully, there is a simple and straightforward way to fix the step therapy process: Congress can pass the Restoring the Patient’s Voice Act of 2017 (H.R. 2077). This bipartisan legislation provides a clear and transparent process to seek exceptions to step therapy review by health insurance plans, and also establishes a reasonable and clear timeframe for override decisions. Importantly, before a health plan can delay or outright deny a patient’s ability to access a medically necessary treatment, the bill requires insurers to consider the patient’s medical history, take into account the provider’s expertise in partnership with their own patient, and respect the health care provider’s professional judgment. 

No patient should be forced to endure ineffective treatments just to satisfy an insurer’s unnecessary step therapy process. Rather, the patient’s relationship with his or her physician – and that physician’s understanding of the patient’s disease and unique medical history – must remain paramount in the clinical decision-making process. That’s why it’s important that Congress stand up for the millions of Americans living with rheumatic diseases and other chronic conditions by supporting this common-sense legislation.  

Sharad Lakhanpal, MBBS, MD is President of the American College of Rheumatology. Ann M. Palmer is President and CEO of the Arthritis Foundation.