Why people “love” their health insurance continues to baffle us. Because anyone who has actually had to use it for anything other than the most straightforward issue has certainly faced hassles.

And we’re not talking about random “someone lost my paperwork” kinds of hassles. Those are understandable to some degree. We’re talking about hassles that result from common health insurance company practices designed to – guess what? Make money.

Let’s take a close look at one such hassle: Step therapy. It’s another way insurance companies save money on your medication.

Cheapest First

Here’s a quick example. After examining you, your doctor prescribes a particular medicine. It’s medicine that was chosen with your specific medical needs in mind. However, it’s more expensive than other medicines that might be used for your disease.

Your health insurer – without examining you – legally denies coverage for the more expensive drug, unless you first try cheaper alternative drugs and prove that they “fail” to work. This is called Step therapy or “fail first,” and it’s a form of “utilization management” which controls the order in which you can access therapies for your condition. Naturally, the preferred order for the health insurer is “cheapest first.”

Does this sound like one of those things that happen to other people, maybe people with exotic diseases? Not really. According to the National Foundation for Women Legislators, step therapy is being applied to many common ailments, including high cholesterol, diabetes, high blood pressure and more.

 

Your Health v Your Health Insurer’s Bottom Line

One example is the case of Danielle Yevsa, who suffers from psoriatic arthritis, an autoimmune disorder. In her article “Denied the drug my doc prescribed . . .” published 9/18/16 in NY Daily News, she writes:

While headlines decry exorbitant hikes in prices for EpiPens and prescription drugs, there is a more insidious practice that happens daily: Insurance companies force patients to take cheaper drugs that are either less effective or outright bad for their health.

….payers routinely force patients to fail on less expensive medications first to test whether they might work or, in my case, not work at all and cause complications, before approving costlier medications.

In fact, there are documented cases of patients being harmed by these practices, as reported in STAT on 8/22/16, “Are insurance policies saving patients money, or keeping them from the treatment they need?”

“The patient’s being told to use a drug we know isn’t going to work, but we have to use it anyway for someone with terminal illness? To me that’s just insane, but it’s the way they do things,” [Dr. Kenneth B.] Blankstein said. “It’s taken away clinical judgment. It’s managing by algorithms.”

No one wants to pay more for anything, on principle. But when it comes to our health, or that of our loved ones, the risk of delaying necessary treatment and possibly getting worse is very high, indeed. If my doctor, who has a duty to care for me, believes I should take a particular medicine, that’s the medicine I want to take. My health insurance company has a duty to their shareholders and they don’t care one whit about me.

Step Therapy on Steroids

Because of the meteoric rise in the cost of pharmaceuticals, what we see today is step therapy on steroids. It’s not surprising that a number of legislative and regulatory solutions are being proposed across the country. But instead of a straightforward ban on health insurers overriding physician orders, these so-called solutions tiptoe around the problem. They add complexity to an intrinsically unethical process.

The only real way to stop it is to require that health insurance companies pay for whatever medication your doctor orders for you.

Step Therapy, Regulations & California

Various legislatures, foundations and advocacy organizations have proposed regulatory actions that they assert would be essential to a “model” bill. Here are some examples:

Ensuring that step therapy protocol is based on current clinical guidelines and developed by independent clinical experts.

Establishing basic exemption requirements to ensure step therapy is safe for patients.

Requiring insurers to standardize step therapy exemption requests, and make sure they are transparent and accessible to patients and healthcare providers.

It’s not clear if this is heartbreaking naiveté or just plain baloney. These regulatory actions just make step therapy more complex, they don’t put a stop to it.

California is often mentioned as a state that has tackled the problem of step therapy. In 2015, the legislature passed and Governor Brown signed AB 374 (Nazarian): Health care coverage: prescription drugs.

This bill provides a process for medication prescribers to request a step therapy override determination from the health insurer, with a deadline for the insurer to respond of either 24 hours in urgent cases, or 72 hours in non-urgent cases. If the insurer fails to provide a timely response, the request for an override will be deemed granted.

While HEAL California is very glad that something has been done, we must point out that per the August 17, 2015 analysis by the California Senate Appropriations Committee, the legislation does not restrict step therapy protocols:

….[AB 374] does not substantially limit the use of step therapy protocols as prior bills have. However, the bill does impose short timelines for health insurers and health plans to consider a step therapy override request.

What you can do

If you believe that it’s ok that a clerical worker in a health insurance company decides which therapies you may access, then you should join America’s Health Insurance Plans (AHIP), the California Association of Health Plans, Blue Shield of California or the California Chamber of Commerce! They all went on record opposing California’s AB 374. Of course.

But if you believe that the health insurance policy you purchased should cover you for treatment and medicines that your physician has ordered for you, then you need to join HEAL California and stay informed about opportunities to make health care better for us all.

To learn more, check out the Understanding Step Therapy Video by Alliance for Patient Access. It explains everything about step therapy in about 3 minutes!