Insurance companies routinely violate the doctor-patient relationship through step therapy — a policy that forces patients to fail first.
Paul Gileno, the president and founder of the U.S. Pain Foundation, explains this “mounting barrier to treatment resulting from health insurers utilize their power to deny needed medications.”
“I needed to do something to reduce my pain and get on the right track. My own health insurer, who I was paying twice monthly, had other ideas,” he writes in a recent piece published at Morning Consult. “They refused to cover the medication my doctor deemed medically necessary, claiming they’d only cover alternative treatments.”
Gileno was the victim of the ubiquitous insurance policy known as step therapy. What is step therapy? According to our handy glossary for patients, step therapy, also called “fail first,” is where health plans require patients to attempt treatment with one or a series of less expensive therapies in order to show that they are ineffective before the insurance company will agree to pay for the medication prescribed by their doctor.
Here’s how Gileno explains step therapy: “To gain medication coverage, patients must adhere to the insurer’s recommendation of a lower-priced and often less effective medication… Step therapy, also known as “fail first” is when an insurer decides a patient must first prove failure on a cheaper, potentially less effective medication before approving the originally prescribed medication. While I learned this was an accepted practice among insurers; it seemed unreal to me that a doctor could prescribe a treatment only to have the insurer ignore his advice.”
The most persuasive argument against step therapy is made by patients who have been forced to fail first.
“In 2014, I began chemotherapy on the drug I was forced to take by my insurance company — which was not the drug my doctor had prescribed,” patient advocate Danielle Yevsa writes in the New York Daily News. “I contracted numerous illnesses and infections from the havoc it wreaked on my already compromised immune system.”
“I had to leave work at least once a week because, when I was vomiting, I could not stop.”
“I missed so much work that I ended up losing not one, but two jobs. My husband lost his job because he had to stay home and care for me. He wasn’t employed long enough to qualify for the Family and Medical Leave Act and we went on welfare.”
“The knowledge that my insurer had so much control over my life was debilitating.”
Read her entire story at the New York Daily News.
Former FDA Associate Commissioner Peter Pitts, the president of the Center for Medicine in the Public Interest, shares more stories of patients that have been harmed by fail first insurance policies. He also points out fail first policies are short-sighted and ultimately drive up our overall health care costs.
“This short-term focus on profits is callous — and counterproductive. Denying patients the best healthcare leaves them sicker, ultimately raising insurers’ expenses,” he says in a piece for the Houston Chronicle.
To support this argument, Pitts cites the case of patients addicted to opioids, who lost ground in their fight against addiction because of the delay.
“Consider the case of Angela and Nate Turner, both addicted to opioids. Their doctor sought insurer permission to prescribe a treatment that lessens drug cravings. As the insurer delayed, precious time passed. Angela became violently ill from withdrawal after waiting for three days. After waiting five days, Nick succumbed to his urges and used heroin.”
Pitts concludes, “If insurers want to help their customers — and their own bottom lines — they need to think long-term and cover treatments that prevent and wipe out diseases.”
From our perspective, step therapy hurts patients by restricting access to the right treatment.
As our policy director Jonathan Wilcox explains, medications, especially treatments for cancer, aren’t easily interchangeable. “Substituting one for another is not the same as swapping out a Coke for a Pepsi and then having an RC Cola. Even the difference of a few nanoparticles can have profound consequences for a patient.”
“Oncologists also say step therapy often doesn’t take into account a patient’s full medical history. Although that may not always be decisive, you don’t need a medical degree to realize the obvious risks.”
Earlier this year, our national Patients Rising survey, which was conducted in partnership with CancerConnect, found health plans routinely deny claims, drop drugs from the formulary after the plan-year has begun, and employ practices such as step-therapy or “fail first” to force patients to take less effective treatments despite the best advice from their physicians. 77% believe that “step therapy” or “fail first” causes cancer patients to take potentially ineffective treatments instead of the therapy prescribed by the oncologist.
As Becker’s Hospital Review points out, insurance companies have been able to increase their profits by denying patients access to the treatments prescribed by their doctors.
For more on step therapy, check out our previous post: “Step Therapy Explained.”