Step therapy is part of a health insurance plan that requires patients to go through a “fail-first” method of medication. When a doctor prescribes a cancer patient a costly drug, insurance companies do not want to pay for the medicine claiming that it will cost too much for the other members. So the step therapy plan is to have cancer patients try other less costly medications before “stepping-up” to the costlier drug. The point of this process is for the insurance companies to know that the cheaper drugs don’t work before the patient’s plan will actually cover the cost of the medicine the doctor originally prescribed.[1] How the insurance companies determine if the patient needs to go up to a higher costing medicine is if they “fail” or don’t get better using the cheaper one.[2] Step therapy has been shown to be steadily increasing. In 2005 only 27% insurance companies had step therapy policies, but in 2013 75% of major insurance companies had step therapy policies. 2 Step therapy is expected to continue to rise to prevent more patients from getting medication (studies have shown that 1 in 5 patients don’t receive any treatment because of step therapy and this is likely to grow). 2
Step therapy policies affect many different patients with a variety of diseases such as: diabetes, mental illness, rheumatoid arthritis, epilepsy, Alzheimer’s, hemophilia, glaucoma, and cancer. I am focusing on the effects of step therapy on cancer patients. In Utah in 2016, 8.91% of Utahans had cancer.[3] Step therapy can delay/lower the patients’ care quality. Since step therapy requires patients to try one or more drugs before being covered for the drug selected by their health care provider, it can delay access to the most appropriate therapy. Because of these delays, patients may experience disease progression, a serious risk for anyone living with a debilitating or life-threatening illness. While this puts a major strain on patients, it also puts a huge burden on doctors. The doctors spend up to three weeks of time a year interacting with health plans.[4] It also places a burden on the patient- clinician relationship because it undermines trust and effort between the physician and patient and also impedes the doctor’s ability to treat the patient as they see fit. There is also a loss of money because of having to spend time debating with the insurance plans. The national cost of time lost to interacting with insurance companies is $23-31 billion dollars annually. 4
Insurance companies are the only ones who truly benefit from the step-therapy policy. Step therapy is to help prevent raising costs. It reduces costs in two ways 1. Directing patients to generic or lower-cost options as first line of care and 2. Avoiding Rx costs altogether when patients opt for no medication after step therapy rejection.4 However, one case study with schizophrenia patients showed that the step therapy policies saved Georgia’s Medicaid drug program $19.62 per member per month. But, the state ended up spending $31.59 per member per month on outpatient services related to ineffective medications. [5]
Since the delay of medication and more patients not getting the treatment they need, people are becoming more aware of the problem. Some states have taken action against step therapy. In Connecticut a bill was passed in 2014 to prohibit insurers from forcing cheaper medication for more than 60 days. [6] Similarly, Illinois requires health plans to provide a reason for denying a prescription drug and gives the option to override step therapy if the treatment is going to be ineffective based on previous medical history. [7] Further, other states have adopted legislation that allows doctors to override insurers, prohibiting step therapy for specific types of drugs, and requiring insurers to cover medically necessary drugs, even those not included on the formulary. [8] In addition to these legislation changes, increased oversight over step therapy is necessary in every state. Most states don’t regulate the step therapy process even though it has a huge impact on patients. States should implement basic standards and some regulatory oversight for step therapy programs
[1] "What Is Step Therapy?" What Is Step Therapy? | Pharmacy. N.p., n.d. Web. 29 Jan. 2017.
[2] "Step Therapy Key Facts." Prescription Process. N.p., 2017. Web. 29 Jan. 2017.
[3] "Cancer Statistics and Publications." University of Utah Utah Cancer Registry Cancer Statistics and Publications. University of Uta, n.d. Web. 31 Jan. 2017.
[4] Charles, D., MD. (n.d.). Understanding Step Therapy. Retrieved January 31, 2017, from http://accc-cancer.org/ossn_network/AZ/presentations/TACOS-Fall2015-charles.pdf
[5] Farley, J., Cline, R., Schommer, J., Hadsall, R., & Nyman, J. (2008, August 30). Retrospective assessment of Medicaid step-therapy prior authorization policy for atypical antipsychotic medications. Retrieved January 31, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/18803994
[6]S. (n.d.). AN ACT CONCERNING REQUIREMENTS FOR INSURERS' USE OF STEP THERAPY. Retrieved February 1, 2017, from https://www.cga.ct.gov/2014/act/pa/2014PA-00118-R00SB-00394-PA.htm
[7] Illinois General Assembly - Bill Status for SB3037. (2017, January 10). Retrieved February 01, 2017, from http://ilga.gov/legislation/BillStatus.asp?DocTypeID=SB&DocNum=3037&GAID=13&SessionID=88&LegID=96375
[8] New York State Assembly | Bill Search and Legislative Information. (n.d.). Retrieved February 01, 2017, from http://assembly.state.ny.us/leg/?default_fld=&bn=A02834&term=2015&Summary=Y&Actions=Y&Votes=Y&Memo=Y&Text=Y
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