Step therapy forces patients to fail first: Congress can fix that
© istock

It has been said that the definition of insanity is doing the same thing over and over and expecting different results. How about being forced to do something you are quite sure will not work, and that might in fact harm, before being allowed to do the thing you know will work?

Absurd, right?

This scenario happens all too frequently in health care. Utilized by a majority of public and private insurance companies, step therapy – sometimes called “fail first” – is a protocol that forces patients to try therapies preferred by their insurance company before the insurance company will approve the one their doctor prescribed, even when doctors believe the “insurer preferred” option will be ineffective or could even harm the patient. By forcing patients to undergo therapies that their doctors expect will not work, step therapy can cause patients unnecessary suffering, increase their risk of developing complications, and delay timely recovery. It also undermines the clinical judgement of physicians in favor of the preferred treatment option of an insurance company.

Unchecked use of step therapy can cause very real harm to patients – particularly those living with complex degenerative and inflammatory illnesses such as rheumatoid arthritis and lupus. Because of the complexity of these diseases and the variabilities in patient responses to therapies affecting the immune system, treatments for these debilitating and painful conditions must be carefully considered and individualized for each patient. Some drugs, for example, may carry a higher risk of adverse side effects for some patients or interact poorly with other prescribed medications used to treat their rheumatic disease or other medical conditions. In some cases, a patient may have already failed a medication in the past but is required by a new insurance plan to try it again before receiving approval for the doctor’s prescribed treatment. 

For rheumatologists, there is perhaps nothing more frustrating than knowing they have medications which can help to relieve a patient’s pain and suffering but being prevented from prescribing them because of bureaucratic policies and red tape.

Fortunately, our leaders in Congress can do something about it.

Last month, Reps. Raul RuizRaul RuizOvernight Health Care — Presented by PCMA — Senators unveil sweeping bipartisan health care package | House lawmakers float Medicare pricing reforms | Dems offer bill to guarantee abortion access Congressional Hispanic Caucus demands answers on death of migrant children Step therapy forces patients to fail first: Congress can fix that MORE (D-Calif.) and Brad WenstrupBrad Robert WenstrupStep therapy forces patients to fail first: Congress can fix that Key doctors group faces political risks on guns GOP announces members who will serve on House intel panel MORE (R-Ohio) – both medical doctors who have encountered step therapy in their own practices – introduced the Safe Step Act (H.R. 2279). This common-sense, bipartisan legislation would create a clear and transparent process for patients with employer-sponsored insurance to seek exceptions to step therapy. It would also establish a reasonable and clear timeframe for physicians to override insurer decisions and would require insurers to consider the patient’s medical history, as well as the provider’s expertise, before denying a patient medically necessary treatment.

As physicians, we have a duty to advocate for the needs of our patients in all circumstances. In Washington, that means fighting for policies that restore the power of physicians to treat patients appropriately and in accordance with accepted guidelines. The American College of Rheumatology is proud to support the Safe Step Act and we urge other members of Congress to join Ruiz and Wenstrup in putting patients – and their health and wellbeing – first.

Paula Marchetta, MD, MBA is a practicing rheumatologist and president of the American College of Rheumatology.