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‘Step therapy’: a serious, unnecessary barrier to patients getting appropriate treatment

Insurance company are essentially determining patients’ treatment plans based solely on what drugs they can get the best price on.

It’s not easy being a patient with a chronic illness like arthritis, but when there are treatments that can keep you more comfortable and functional, life can still be productive and enjoyable. Unfortunately, getting appropriate treatment is harder and harder these days.

Dr. Jody K. Hargrove

I am a rheumatologist who sees patients with many types of arthritis and autoimmune diseases that are treatable but not curable. Long-term treatment is necessary, and often the medications need to be changed periodically because they lose effectiveness or are not tolerated. Not only do my patients deal with joint pain, stiffness, fatigue and a host of other symptoms daily, now they often face barriers to appropriate treatment erected by insurance companies and pharmacy benefit management companies. It’s not right, and now lawmakers here in Minnesota are helping doctors and patients push back on these unfair practices.

An example of such a barrier is a practice known as step therapy — or fail first. It’s not therapy at all, but a clear break down of how health care should work. As a physician, when I am working with a new patient to provide a treatment plan or an established patient that needs a change in their drug regimen, I assess the severity of their current rheumatic condition, how it impacts their life, review their other past and current medical conditions, and review their other medications. Then together the patient and I determine the best course of treatment to manage their disease. The barrier to care arises when my patient takes their prescriptions in to be filled, and the pharmacist tells them that their insurer won’t cover the prescribed medication until we prove that medications on the insurers preferred list don’t work — hence the “forced failure.”

The insurance company essentially determines the patient’s treatment plan based solely on what drugs they can get the best price on. The patient’s other health conditions, other medications, concerns about drug side effects, and severity of disease are never considered, only the cost. The insurer feels they escape culpability by telling the patient they can fill any prescription — but at their own personal expense. 

It’s heartbreaking — and frankly, morally wrong — when you see a patient with hope that they might get some relief from their symptoms only to be told they can’t have the appropriate treatment. Arthritis patients whose disease is not adequately treated will have significantly more joint damage. Damaged joints lead to loss of motion, joint deformities, joint surgeries, and often disability. This course is devastating for the patient. Newer therapies in the last 15 years have made a significant difference in this prognosis, but step therapy is limiting access.

In states across the nation, my colleagues, patients, and their advocates have worked to change this — passing common-sense step therapy reform legislation. And now, in Minnesota legislation has been proposed to do the same. Rep. Kelly Fenton and Senator Paul Utke are leading the charge for patients, with their step therapy reform bills (SF 2897/HF 3196).

These reforms do not eliminate step therapy, but make it a more workable and patient-focused process. More than a dozen states have passed similar laws in recent years, and it’s my sincere hope that Minnesota lawmakers see the clear reasoning for doing the same for our state residents. 

It’s time that we put patients first and eliminate unnecessary barriers to good care. Please join us in urging our state lawmakers to seriously consider step therapy reform this legislative session.

Jody K. Hargrove, M.D., is the president of the Rheumatology Association of Minnesota and the Dakotas.


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Comments (1)

  1. Submitted by Joan Asmus on 04/06/2018 - 08:10 pm.

    The Epilepsy Foundation of Minnesota supports this bill as it is understood that step therapy laws have impeded the appropriate drug therapy for individuals with seizures as well. Why would an insurer want someone to have to fail treatment – have a potentially life threatening seizure- before approves what the providers determines is best course? Let’s allow providers to make the decisions with the patients.

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