Step therapy: Harmful delays and the patient may suffer

It’s never a good idea when insurers cut costs by interfering in the decision-making process between patients and their doctor. But during a national pandemic, it’s a particularly bad idea. 

I am thinking specifically of an insurance strategy called step therapy. It happens when insurance companies require patients and their providers to prove that insurer-preferred alternatives don’t work before covering the physician-prescribed medication.

Insurers typically require patients to try the least costly medicine approved for the condition being treated.

Frustrated patients and health care providers knowingly refer to this as “fail first.” That’s because it asks patients to suffer through the ineffectiveness or unnecessary side effects of a medicine picked by their insurer rather than the one their health care provider thinks is a better fit. Only after patients complete an often-lengthy process of trying and failing multiple medications does the insurer agree to cover the physician’s recommendation.

Insurers typically require patients to try the least costly medicine approved for the condition being treated. This assumes that all medications approved for a particular condition are equal, which is just not true. The art of medicine is choosing the medication that is the best fit for each patient based on his or her unique circumstances. A cost-based algorithm doesn’t consider such nuances. And, ironically, it may actually cost insurers and patients more in the end.

Insurers could save money if step therapy were eliminated, for example. They wouldn’t need staff to review providers’ appeals. Patients could save on unnecessary appointments and preventable emergency care.

Step therapy sometimes can be part of a logical treatment approach. Health care providers of their own volition may guide patients to try a simpler, less expensive or time-tested treatment as the first option. But that’s the health care provider, who has been through years of training and who understands the patient and the patient’s history, making the recommendation.

Under insurers’ direction, the decision can be arbitrary or cost based – meaning the insurer promotes the drug of whichever company has offered the insurance company the biggest price concession that year. In some cases, step therapy can even put patients’ health at risk.

The dangers of step therapy are not new information to California legislators. Since 2015, our state has mandated that insurance companies provide a timely response to providers who want  to bypass step therapy requirements. Depending on urgency, insurers have 24 to 72 hours to approve or deny the treatment request. But even with quick turnaround times for exemption requests, step therapy is still a frequent frustration. Physicians want to focus on patient care, not excessive paperwork.

In 2017, almost 60,000 patients died from cancer. Nearly 10,000 succumbed to diabetes that same year. Treatment for both conditions involves prescription medications.

The COVID-19 pandemic has given an interesting twist to the step therapy debate.  Some companies have, either voluntarily or at the direction of state policymakers, waived step therapy for COVID-19 treatment. It’s a commendable action. And yet it reveals that insurers themselves recognize step therapy as a problem.

If it’s that evident to everyone that step therapy causes potentially harmful delays, perhaps it’s time for policymakers to consider restricting the practice for patients trying to manage the impact of all harmful diseases – not just the novel coronavirus. 

Nearly 6,500 people in California have died from COVID-19. That tragic toll deserves policymakers’ attention and resolve to combat this disease. But perhaps it can also serve as a reminder of policymakers’ responsibility to the thousands of Californians who die from other illnesses too. In 2017, almost 60,000 patients died from cancer. Nearly 10,000 succumbed to diabetes that same year. Treatment for both conditions involves prescription medications.

It’s wonderful to see health plans waiving step therapy and other utilization management barriers for patients with COVID-19. If this approach makes sense for COVID-19, shouldn’t it make sense after the pandemic and for other conditions too?

Patients with COVID-19, and with any serious illness, will surely struggle to stay healthy without prescribed medication and adequate care. If the fatalities from COVID-19 have set California legislators’ sights on protecting patients, one valuable step would be passing commonsense laws to shield them from insurance practices that block access to prescribed medication.
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Editor’s Note: Rimal Bera, MD, is a clinical professor of psychiatry at the UC-Irvine. His primary area of specialty is adult psychiatry with a focus on schizophrenia, bipolar disorder, depression and memory disorders.