By Edward Goldberger, M.D., F.A.C.R.
I am doctor of medicine. If you are my patient, I know your unique health needs on a very personal level. Your health insurer knows you too, but not as well as I do. Still, that won’t stop a health insurer from interfering with my care for you and placing barriers to treatments I feel are necessary and indicated. Prescription medication is one area where health plans may deny what I prescribe, and force a different medicine on patients.
The practice is called “step therapy” and is increasingly imposed on patients by their health plans.
Step therapy occurs when insurance carriers deny prescribed medication and require the patient to try a medication that the health plan prefers sometimes because it costs less. While this may save some money for the insurer, it can jeopardize the health of my patients. This process is also known as a “fail-first” approach, as in, “Try this drug first. If it doesn’t work, we’ll try another one.”
As a rheumatologist, I treat patients with complicated musculoskeletal and systemic autoimmune conditions such as rheumatoid arthritis and systemic lupus commonly known as rheumatic diseases. These diseases can affect the joints, muscles and bones causing pain, swelling, stiffness and deformity and may even cause internal organ damage. These complex conditions can do considerable damage to a patient without adequate treatment within a short three to six months. When my patients are forced to “fail first,” irreversible health setbacks can occur.
When I prescribe medication, I must choose the treatment that is best and safest for my patient. Step therapy requirements often ignore the fact that a prescriber has chosen a medicine that is safe for their patient to take, considering that person’s unique health needs. “Contraindication” is term we use when a medicine may be unsafe for a patient. Contraindications do not matter to insurance companies. They save money and the prescribing physician bears the liability if there are resulting issues. With step therapy, prescribers have to fight for patients to get the safest, most appropriate medicines for their individual situation.
Adding another burden is the fact that the process to bypass a step therapy required medication involves a lengthy and tedious appeals process.
Our practice recently saw a rheumatoid arthritis patient from Toledo in her mid-40’s, working full-time and experiencing severe bouts of painful stiffness in her joints and generalized fatigue. Our patient was prescribed a medication that her treating physician thinks would have best addressed her challenging health issues.
Her insurance carrier denied the medication as it was predetermined by step therapy what medications she would be allowed. This patient has a strong family presence of Multiple Sclerosis (MS). Both of the medications the insurance company approved have a known side effect of potentially triggering MS. This patient is being forced through a physically and emotionally painful appeals process to get the medications safest for her needs.
Step therapy practices need to be reformed in Ohio. Eleven other states have passed laws to lower step therapy hurdles. More than 50 Ohio health advocacy groups, including physicians, and organizations that serve patients with arthritis, mental illness, diabetes, cancer, MS and more are working together to ask lawmakers to support Ohio House Bill 56 and Ohio Senate Bill 72.
H.B. 56 and S.B. 72 propose requiring step therapy decisions to be based on medical guidelines developed by medical experts, not bottom-line focused accountants; specifying conditions where certain patients would be exempt from step therapy; and most important, requiring a clear appeals process.
The step therapy roadblock to providing adequate care to our patients needs to be addressed. Readers may call their local legislators and ask for support for these bills.
Dr. Ed Goldberger is a rheumatologist practicing in Toledo and also an active board member with the Ohio Association of Rheumatology.
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