Reform flawed “step therapy” to put patients first
A significant burden to patients — and to health care providers — is the common insurance company practice of overriding a physician’s drug recommendation and requiring a patient to use, and fail on, a lower-cost drug before it will authorize use of the more expensive, physician-preferred, drug. Known as “step therapy” — or more commonly among professionals “fail first” — this practice creates unwarranted suffering for patients and untold frustration for physicians. That’s why we at the Chronic Care Collaborative believe it’s time for the Colorado Legislature to step into the step therapy debate and address this growing health care challenge across our state.
We strongly support Senate Bill 203, which makes reasonable and common sense reforms to the practice of step therapy while still allowing it as an option for controlling insurance costs.
For example, it is illogical to force terminally ill patients to undergo step therapy. Patients with less than six months to live shouldn’t have insurance companies adding to their burdens by requiring them and their families to jump through bureaucratic hoops to get the medication they need. Senate Bill 203 puts compassion first and prohibits step therapy for these patients.
It is also illogical, and frankly somewhat cruel, to require patients to go through the same step therapy process if they change insurance carriers. Imagine a patient who waits to fail on the first drug, finally obtains the physician-preferred drug and then, for whatever reason, changes insurance carriers — which can be the choice of their employer. Why should the patient have to start from square one when it’s been demonstrated that the lower-cost drug simply doesn’t work? Senate Bill 203 prevents insurance companies from requiring patients to repeat the step therapy process.
The reform legislation also empowers physicians. If a doctor can show that the drug the insurance company prefers is problematic or will likely cause an adverse reaction in the patient, the patient can get the initial insurance company determination overridden and get the medication his or her doctor prescribed.
We believe that this common sense, compassionate reform bill strikes the right balance in addressing some of the clear problems with step therapy. But the legislation also respects the need of insurance companies to control costs and keep premiums as low as possible. That’s why the bill doesn’t ban step therapy altogether, nor does it require the coverage of any specific medication. It also doesn’t interfere with the cost of the physician-preferred medication or how insurance companies handle copays, coinsurance or formularies for specific drugs.
As with many other aspects of our health insurance system, we learn what works, and what doesn’t from real world experience with patients. When we see a practice, such as step therapy, that needs reform to achieve its goal of controlling costs without threatening the quality of patient care, it’s time to act. We urge our legislators to restore the right relationship between doctors and patients and pass Senate Bill 203.
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The Chronic Care Collaborative blog is dedicated to the 1 in 4 Coloradans living with chronic disease and is a needed voice in healthcare which will advocate for access to affordable coverage and care regardless of health condition.
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