‘Step therapy’ a prescription for failure

Many Californians face restricted access to health care due to dangerous and expensive health insurer policies that prevent patients from getting timely and effective treatments.

Some California health insurers have implemented draconian restrictions in the name of cost containment that place them squarely in the middle of the physician-patient relationship.

One such barrier is a policy known as “step therapy” or “fail first.” Step therapy requires that patients try and fail on up to five older, less effective medications before the insurer will cover the treatment originally prescribed by the doctor. Under this policy, patients are often forced to try and fail on these treatments even when they have already tried them in the past, and even when their doctor knows the treatments will not work.

The practical impact is that California patients — many of whom suffer from chronic conditions or debilitating pain or mental illness — will unnecessarily go for days, weeks, or months without their doctor-prescribed treatment. In short, step therapy hurts Californians, prolongs ineffective treatment, and prevents patients from starting the treatments their doctors think are best.

While it would be tempting to dismiss step therapy as a mild inconvenience, the unnecessary burden has very real health and economic consequences. Delays in treatment can exacerbate health problems and often allow manageable conditions to deteriorate.

Imagine, as an example, a single mother living with rheumatoid arthritis. When she is denied access to care, it is not only her physical condition that suffers. Every unnecessary visit to the doctor or pharmacist requires out-of-pocket co-pays. Unnecessary medical appointments can also lead to additional days of missed work, which in turn results in loss of wages, as well as drives up costs for her employer through lost productivity and increased insurance premiums.

A recent analysis from the California Health Benefits Review Program (CHBRP) found that those living with and managing mental illness are particularly susceptible to the negative effects of step therapy protocols. CHBRP found that, when faced with the additional barriers to care mental health patients are more likely to stop taking their medication, which can lead to dire consequences, including hospitalizations, suicide attempts, and even imprisonment. In addition to the serious health consequences, unnecessary emergency room visits and increased imprisonment drives up the direct costs to all California taxpayers.

Advancements in science and medicine have yielded new treatments that can more effectively treat patients and speed up their recovery. Unfortunately, Californians will only be able to access them when we require the insurance companies to limit their step therapy practices. Patients must not be asked to bear the unnecessary physical and emotional burdens of step therapy.

In an effort to address this issue, I have sponsored Assembly Bill 889, which directly addresses step therapy’s burden to patients. AB889 is common-sense, patient-protection legislation that will limit step therapy for all medicines to no more than two steps. In addition, it will prohibit requiring a patient to go through step therapy again if the patient went through it when covered by another plan.

In this critical era of health care cost containment, AB889 preserves step therapy as a tool for California insurers, but also keeps decisions about how best to treat patients in the hands of their doctors. AB889 also will help lower the long-term costs of health care, as patients can be appropriately treated for their conditions and not be forced to try outdated medications.

California legislators must take action now to ensure that all patients can access the treatments their doctors think are best. Our constituents are frustrated with current restrictions and it’s important that decisions about how to treat patients reside with doctors, not insurance companies.
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Eds’ Note: Assemblyman Jim Frazier, D-Oakley, represents the 11th Assembly District.