Reform Step Therapy Practices 

Step therapy, sometimes known as “fail first,” is a practice employed by many insurers that requires patients to try lower-cost therapies before being approved for the treatment that their doctor prescribed – even when doctors are certain that the cheaper option won’t be effective. 

When inappropriately used, step therapy undermines the clinical judgment of health care providers and put patients’ health at unnecessary risk.  

Many patients must try multiple drugs before finding one that works for them, so the ability to remain on a drug that works is critical. A survey of more than 1,400 patients conducted in 2016 by the Arthritis Foundation revealed: 

  • Over 50% of all patients reported having to try two or more different drugs prior to getting the one their doctor had initially prescribed.  
  • Step therapy was stopped in 39% of cases because the drugs were ineffective, and 20% of the time due to worsening conditions. 
  • Nearly 25% of patients who switched insurance providers were required to repeat step therapy with their new carrier.  
  • A majority of respondents experienced negative health effects from delays in getting on the right treatment. 

Step therapy should not disrupt a patient’s ongoing care or destabilize treatment if they change jobs or insurance carriers. People with arthritis depend on life-changing medications to prevent further progression of the disease and joint degradation. Step therapy requirements can be less administratively burdensome to patients and providers if exceptions are provided in cases where: 

  1. The treatment prescribed is contraindicated or has been ineffective in treating a patient’s disease; 
  2. The treatment under a step therapy protocol is reasonably expected to be ineffective; 
  3. The treatment may cause an adverse reaction or physical harm to the patient; 
  4. The treatment is not in the best interest of the patient or could interfere with the patient’s ability to complete activities of daily living; and 
  5. The patient is stable for his or her disease on medications already selected by a provider. 

What Congress can do.

Congress can pass the Safe Step Act (H.R. 2279). This bipartisan legislation was first introduced in the 115th Congress by Representatives Brad Wenstrup, DPM (R-OH) and Raul Ruiz, MD (D-CA) who have both encountered step therapy in their own practice of medicine. 

The legislation streamlines step therapy for patients with employer-sponsored insurance by establishing a clear exceptions process for step therapy review by health insurance plans; establishing a reasonable and clear timeframe for override decisions; and requiring insurers to consider the patient’s medical history, the provider’s expertise in partnership with their own patient, and respect for the health care provider’s professional judgment – before a health plan can delay or outright deny a patient’s ability to access a medically necessary treatment. 

Step Step Therapy Federal Map

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