What Americans are saying about step-therapy reform

11.2.16

A bill awaiting the New York governor’s signature would enact reforms that could protect many consumers in that state.

Breast cancer patient Cynthia Rogers wrote in The Buffalo News that Gov. Andrew Cuomo, spurred to action by the diagnosis of his partner, Sandra Lee, pledged $90 million to fight cancer and to make it more affordable and easier for women to get screened.

He now has another opportunity to sign a bill passed by state lawmakers in the most recent session that would help, she said, to “ensure patients have access to the most effective and appropriate medications prescribed by their doctors to treat their cancer.”

The legislation targets step therapy, whereby insurance companies can make patients try cheaper treatments than the ones their doctors prescribe before they can move on to a more expensive treatment, even if their doctor is confident the inexpensive treatment won’t work.

The New York law would create a path to appeal health insurers’ decisions to reject filling prescriptions and would require them to respond to appeals within 24 to 72 hours.

“Step therapy doesn’t affect just cancer patients, but a wide swath of chronic conditions,” Rogers wrote. “In many cases with cancer patients, it’s not their radiation or chemo that’s put through step therapy, but other supportive medications to fight the side effects of treatment, like nausea or fatigue. Having recently gone through treatment for breast cancer, at the age of just 46, I know how important having access to these medications is in order to have a good quality of life – while fighting for your life.”

“Having recently gone through treatment for breast cancer, at the age of just 46, I know how important having access to these medications is in order to have a good quality of life – while fighting for your life.”

It isn’t only breast cancer patients who face harm from step therapy, and it’s not only in New York.

Here’s what people are saying about the need for step therapy protections in the United States:

  • Kenneth Bandler, a member of the National MS Society, pointed out that multiple sclerosis patients also have a lot to lose from step therapy.

    He wrote in a recent opinion piece that MS is “a chronic disease that is highly unpredictable. Symptoms vary broadly among those who have been diagnosed. For many the right medications and following the prescribed regimen by a doctor who is familiar with the patient are essential to living their lives as fully as they possibly can.”

    “Insurers should defer to the wisdom of health care providers,” Bandler said.

  • In California, state Assembly member Adrin Nazarian (D-Sherman Oaks) authored a bill to help patients and health care providers get around step therapy, which is “disastrous to some patients with severe illnesses such as lupus, epilepsy or multiple sclerosis.”

    “Keeping health care costs down is important,” Nazarian said, “but we must not allow cost-cutting to become more important than a patient’s well-being.”

  • Dr. Kenneth Blankstein, an oncologist in New Jersey, encountered the issue when treating a woman for lung cancer.

    “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?” he said. “To me, that’s just insane.”

  • In the article “Egregious insurance practice jeopardizes patients’ health,” Kathleen Arntsen of the Lupus and Allied Disease Association in New York wrote that step therapy “can have dire implications and dangerous consequences for autoimmune patients like me who don’t fit a one-size-fits-all treatment standard.”

    “I ask insurers to contemplate the ethical implications of forcing patients to first fail on cheaper treatments before receiving the most appropriate therapy as prescribed by their provider,” she wrote. “A physician is educated and ethically bound to treat to the uniqueness of a patient and do no harm. It is absolutely unethical for payers to jeopardize the health and well-being of vulnerable patients by allowing them to go backwards in their care; causing instability, adverse events, medical complications, allergic reactions, emergency-room visits and even hospitalizations, instead of covering a therapy that the treating provider prescribes.”

    Step therapy breast cancer