Some insurers are forcing patients with diseases such as psoriasis and psoriatic arthritis to try, and fail, one or more treatments before approving the medicine originally recommended by their doctors.
This practice, known as step therapy or “fail first,” is delaying appropriate treatment for patients with these diseases. One recent survey found that 67 percent of patients whose specialty prescriptions were rejected under step therapy policies did not receive an alternative within 30 days.
Delays can be detrimental to patient health. For patients with psoriatic arthritis, for instance, they can lead to worsened bone and joint deterioration and a lower likelihood of success with appropriate therapies.
“It’s all about costs,” Dr. Philippe Saxe, managing partner at Arthritis Associates of South Florida in Delray Beach and immediate past president of the Florida Society of Rheumatology, said. “It has nothing to do with the specific patient’s condition or medical history.”
Some insurance plans, for instance, unreasonably require patients with moderate to severe psoriasis first try topical treatments — creams or ointments — even if they need to treat a large body area.
Meanwhile, other insurers force patients with psoriasis or psoriatic arthritis to try the newest innovative therapies in a specific order, known as sequencing, without regard for physician’s discretion.
It’s all about costs. It has nothing to do with the specific patient’s condition or medical history.
Policies such as these often do not take into account therapies the patient has previously tried and found unsuccessful in years past. It may also ignore patient-specific contraindications, side-effects, or logistical challenges.
Because insurers provide little transparency to their step-therapy policies, patients and doctors often don’t learn about the specifics until the patients’ attempts to fill their prescription at their local pharmacy are rejected.
That’s when the paperwork and administrative burdens begin. Doctors and their staff are required to fill out documents and call the insurer to help their patient get the more appropriate treatment. “It’s an extremely time-consuming and frustrating process for both physicians and patients,” Saxe said.
David Steingart tells us the hardships he has seen due to step therapy. Read more from his testimony at http://t.co/ge0TtSpawQ
— Patient Access FL (@PatientAccessFL) February 24, 2015
Beyond eliciting frustration and wasted time, these policies also increase health care costs and the economic burden of psoriasis, which reached an estimated $112 billion in 2013 in the U.S., including direct costs and lost productivity.
Changing therapies requires patients to pay additional copays for doctor visits and prescriptions and to spend more time away from work and family. And as we have seen in other diseases, restricting access to effective therapies can also lead to more frequent hospitalizations that increase overall costs.
“The vast majority of doctors will prescribe the least expensive medicine if it is appropriate, but there are occasions where the least expensive is not the most effective option,” Saxe said. “Physicians need the ability to override step-therapy policies.”
The efforts of Saxe and other physicians in the Florida Society of Rheumatology have been instrumental in efforts to pass legislation in Florida, bill SB 784, that allows bypasses in certain situations, such as a history of side effects with the least expensive option. It will also prohibit insurers from creating step-therapy protocols that are not supported by sufficient clinical evidence.
Other states, including New York, California, Missouri, Illinois, Maine, Massachusetts and Rhode Island, are considering similar legislation to protect patients from step therapy policies.
There is precedent for success with such bills; last year, Connecticut passed a bill that prevents insurers from forcing patients to take a less expensive treatment option for more than 60 days. And advocates are calling for national action as well.
“This is important legislation that will allow the patients to get access to necessary treatments,” Saxe said.