By Jonathan Wilcox
Health insurance companies are constantly looking for ways to hold down costs. Since America’s health care system has a price tag of nearly $3 trillion, the impulse is understandable.
One tactic insurers are frequently implementing requires that patients “step” through older, less expensive therapies before being given access to more expensive drugs when two medications are equivalent.
Insurers benignly call this “step therapy,” but millions of people in need of prescription therapies call it something far more sinister: “fail first.” And a national movement is under way to stop it from California to New York.
On the surface, the idea might make sense: patients are getting essentially the same drugs and insurers save millions of dollars a year on drug costs.
Trouble is, only one of those things is true. And for cancer patients specifically, their experience with this widespread policy is not only unfair, it’s downright unsafe.
First, medications are rarely, if ever, equivalent. Substituting one for another is not the same as swapping out a Coke for a Pepsi and then having an RC Cola. Even the difference of a few nanoparticles can have profound consequences for a patient.
Oncologists also say step therapy often doesn’t take into account a patient’s full medical history. Although that may not always be decisive, you don’t need a medical degree to realize the obvious risks.
“It’s taking the decision away from the physicians and the patient,” said Stacey Worthy, director of public policy for the Alliance for the Adoption of Innovations in Medicine. She recently told a Vital Options panel discussion, “That means 20 percent of patients don’t ever get the treatment they were actually prescribed.”
Imagine 20 percent of broken arms not getting a cast and sling as prescribed by an orthopedist, or 20 percent of root canals performed using a different, cheaper procedure that may or may not leave with you an abscess.
A recent study published by the International Society For Pharmacoeconomics and Outcomes Research (ISPOR) found that safety was ignored in 18 insurance formularies covering 45 percent of patients taking immunological agents and biologics, typically for inflammatory conditions such as arthritis or psoriasis.
The analysis also found it actually exposes patients to medications with potential side effects so serious the Food and Drug Administration imposes what are widely known as “black box” warnings.
The publication Drug Watch describes it this way: the Food and Drug Administration requires a black label “if serious or life-threatening risks are associated with the drug.”
“Black box” medications are not banned, nor should they be. Sometimes they are the only treatment option a doctor will make available to a patient. But now that newer, safer treatments with no such warnings are available, how or why does an insurance company get to save money at the patients’ expense by forcing them to try a treatment with known life-threatening risks?
Worthy describes an emerging “triumvirate of trouble” from contemporary insurance practices: the “Fail first” requirement; high copays for cancer drugs, and lower levels of reimbursement for medications given by mouth instead of by needle.
In 2009, Oregon began considering a requirement that insurance companies provide equal reimbursement for oral cancer medications and drugs delivered intravenously. Six years later, 39 states and the District of Columbia have passed oral drug parity laws.
Last month, California’s Obamacare exchange issued a new regulation making it the eighth state to cap patient copays for prescription drugs and the third in 2015. Other states are following suit.
This month, the California Assembly overwhelmingly passed AB 374, which allows a doctor to request a step therapy override from a health plan or insurer. The bill’s author, Assemblyman Adrin Nazarian, D-Sherman Oaks, said, “Keeping healthcare costs down is important, but we must not allow cost-cutting to become more important than a patient’s well-being.”
Last month, New York’s State Legislature heard from Suzanne Carrow, who has been fighting cancer for 16 years: “I had been on a drug for a long time and then all the sudden, the insurance company is saying no, you can’t, you’re going to have to be on all of these different drugs.”
Patients like Suzanne Carrow aren’t just in New York. They’re everywhere. Now, they are finding their voice. If they are heard widely enough, “step therapy” can be stopped in its tracks.
Jonathan Wilcox is policy director of Vital Options International, a nonprofit cancer communication, education and advocacy organization. www.vitaloptions.org