Health insurance companies would no longer be allowed to unilaterally force patients to fail first on cheaper and less effective treatments, under a bipartisan proposal gaining widespread support on Capitol Hill.
The Safe Step Act would implement new guidelines to aid patients in their fight against insurance step therapy requirements, which require patients to use treatments that are the most profitable for insurance companies rather than the treatments prescribed by a patient’s doctor or other care provider.
“Doctors and patients should not have to work through multiple medicines which have already failed or which may cause more harm than good,” said Senator Bill Cassidy of Louisiana, a physician and co-author of the step therapy reform legislation. “This bill allows the proven right medicine to be given as soon as possible.”
The bill would require employer-sponsored health plans that use step therapy procedures to implement a clear process for patients to request an exception. It would also establish five automatic patient exemptions from step therapy, including when a patient has already tried and failed on the insurance treatment, when the insurance treatment will harm a patient’s health, or when the insurance treatment impedes a patient’s ability to work or perform routine daily tasks.
“For too many, step therapy is known as ‘fail first’ because it forces patients to try and fail treatments before getting what their doctor originally prescribed,” said Rep. Brad Wenstrup of Ohio, a physician and co-author of the House version of the bill. “This can lead to dangerous delays in treatment and additional costs for the patient and our health care system.”
Step Therapy: Patients Must Fail First to Boost Insurance Profits
Step therapy, a widely-used insurance practice, forces patients to attempt a series of less expensive therapies in order to show that they are ineffective before the insurance company will agree to pay for the medication prescribed by their doctor. Patients say that fail first insurance requirements result in months, or even years, of suffering.
“Without ever examining you, insurance companies can veto your doctor’s advice and force you to fail on the wrong treatment,” explains Terry Wilcox, executive director at Patients Rising, a national patient advocacy non-profit organization that supports step therapy reform legislation. “Every medical decision should be based on the best interests of the patient, not insurance profits.”
A 2016 Patients Rising survey found that 77 percent of patients say that step therapy undermines their health care by forcing them to use ineffective treatments.
“Step therapy delays treatment and can be harmful,” explains JP Summers, a migraine patient in Wisconsin who spent four years battling his insurance company to get approved for the migraine medication prescribed by his neurologist. “For me, I had to cycle through less expensive medications that my doctor (correctly) suspected would not work, caused side effects and hospitalized me six times.”
That type of abusive insurance protocol would be barred by the Safe Step Act.
“This common-sense, bipartisan legislation would create a clear and transparent process for patients with employer-sponsored insurance to seek exceptions to step therapy,” writes Dr. Paula Marchetta, a practicing rheumatologist and president of the American College of Rheumatology. “It would also establish a reasonable and clear timeframe for physicians to override insurer decisions and would require insurers to consider the patient’s medical history, as well as the provider’s expertise, before denying a patient medically necessary treatment.”
In addition to hurting a patient’s health, step therapy also drives up long-term health care costs.
“Denying patients the best healthcare leaves them sicker, ultimately raising insurers’ expenses,” argues former FDA Associate Commissioner Peter Pitts, president of the Center for Medicine in the Public Interest. “If insurers want to help their customers — and their own bottom lines — they need to think long-term and cover treatments that prevent and wipe out diseases.”
