Dr. delfin santos 

Rochester Hills / Rheumatologist 

Dr. Delfin Santos is a rheumatologist with a practice in Rochester Hills, Michigan. He shared his experience with step therapy and how it is detrimental to his patients’ health and how it interferes with his ability to treat them.

Step therapy has been a major hurdle for me in treating my patients.   The processes and paperwork my office has to complete take up too much of my time, and that of my team.  I have two people working constantly to get authorizations for medications and they’re on the phone at least four or five hours each day.  Different insurers have different step therapy systems, so it’s a very complicated and cumbersome field to navigate.

All of the hoops we have to jump through just to get our patients the right medicines take time away from treating our patients.  It interferes with almost everything in the office including quickly getting our patients their test results. 

The much bigger problem with step therapy is that it negatively affects patient health.  When patients come to me suffering from their rheumatoid conditions, I know that an aggressive treatment plan can help ease their immediate pain and prevent long-term, serious, irreversible joint damage.  But, I also know that the insurance companies will deny coverage of these drugs as an initial step, even though prescribing them is the most appropriate and effective thing to do.  It’s a serious concern that this process is taking decision-making away from the doctors that examine patients and know their health conditions.

For example, I have a patient who is suffering from rheumatoid arthritis (RA).  Her sister has multiple sclerosis.  Because of my patient’s family history, I avoid putting her on a certain RA medication because I know that the drug can trigger MS in rheumatoid arthritis patients.  But that RA medication is the first “step” her insurance company requires her to try.  I don’t want my patient to develop another harmful condition just because the insurance company is trying to save money.

Another patient of mine is suffering from some very bad side effects that could have been avoided.  She has latent tuberculosis and her insurance company’s step therapy plan dictated that I prescribe her anti-TNF drugs that, I know as her doctor, were contraindicated for her case.  The medicine that I knew would be most effective for her was in the insurer’s formulary, but was not the first, second, or even third option on the step therapy list.  So, now she endures extreme discomfort while we fight for her to get the treatment she needs.

This process can be even worse for patients when they switch insurance companies or are referred to us from another doctor.  In those cases, insurance companies want to force them to into step therapy again -- even when the patients and I know that certain medications just don’t work for them.  As a result of these delays in implementing the right treatment, these patients get sicker.  With rheumatoid arthritis patients, the condition affects the whole body.  Getting the right treatment as quickly as possible can save lives by preventing subsequent illnesses like heart disease.

My advice for patients is to not let insurance hassles prevent you from getting the treatment you need.  Keep seeing and talking with your doctor, make appointments, and let insurers know when their preferred treatments aren't working.  I know it’s a very frustrating process for patients but it is critical that they advocate for themselves in order to get the right medicine for their health conditions.  I also tell other doctors that they need to keep fighting for their patients and raising their voices against policies that put patient health and lives at risk.