Escaping the Madness of Step Therapy
By Randall Rutta, Executive Director, Let My Doctors Decide
Patients with autoimmune diseases like multiple sclerosis have described their conditions as feeling like their bodies are in a prison from which they are unable to escape. Too often, that sense of imprisonment is compounded by the way in which insurers and pharmacy benefit managers (PBMs) are confining and controlling patients and medical professionals, strictly limiting their efforts to achieve greater health.
For people with chronic conditions, step therapy is an ill-conceived, economically-driven practice that requires patients to try several insurer-preferred drugs before their insurer will cover the medicine that their doctors originally prescribed. This ‘fail first’ practice is an insidious mechanism, designed to save insurance companies money even though it harms those most in need of specific medications and treatments, particularly individuals with autoimmune diseases.
To help raise awareness of the harmful effects of step therapy, Let My Doctors Decide (LMDD) released a set of patient principles and a petition that will be sent to federal and state/local policymakers encouraging reforms and raising awareness of the harmful ramifications of step therapy. The principles state that:
Patients and physicians should make individual treatment choices.
You cannot treat all autoimmune diseases the same, as responses to therapies vary widely from patient to patient.
Patients should have access to easily understood information about their coverage: what is covered, how much it will cost them personally, and how to get coverage approved for the treatment they need.
At the pharmacy counter, patients should receive discounts, rebates, and other insurer and non-insurer savings that help make medicines more affordable.
Escaping the madness of step therapy will be a focal point at the upcoming American College of Rheumatology Annual Meeting in Atlanta this week. LMDD will host an “escape room” – an interactive maze -- to illustrate, first-hand, the frustrations associated with step therapy and “fail first” protocols. The “Escape the System” simulation is designed to demonstrate the control and confinement of step therapy, show how it second guesses providers’ expertise, interferes with the doctor-patient relationship, and negatively impacts patient health.
The clinician-patient relationship is an incredibly powerful force in our healthcare system for improving health outcomes. Treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or PBMs. Ill-conceived “fail first” strategies undermine the clinician-patient relationship, harm patient health, increase the paperwork burden on clinicians, and add unnecessary costs.
Patients should not be required to find an escape route in order to receive the doctor-recommended medicines and strategies for improved health and wellness. It’s time to stop the step therapy madness.