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System costs health, money

I am responding to an opinion article that tries to rationalize Step Therapy (“Step therapy vital to appropriate care,” Dr. Eugene Sun, Blue Cross/Blue Shield of New Mexico, Jan. 3). Step therapy means that insurance companies will only pay for the medicines that are the least expensive, even if the patient needs a different medication for legitimate medical reasons. It doesn’t matter if a patient has been stable on a different medicine, or has not tolerated the medicine preferred by the insurance company. Doctors choose medicines to prescribe based on how well they work for the individual patient, taking into considerations their unique conditions. Insurers and Pharmacy Benefit Managers (PBMs) require the use of the drug that is most profitable for the PBM. To say that step therapy is always appropriate is to argue that doctor’s orders should be ignored, medications are interchangeable, and patients can wait through long periods of sickness and failure before getting therapy that works.

In truth, step therapy can be a hazard to patients, who are asked to “fail first” under a drug decided by the insurance company before getting the drug their doctor thinks is their best treatment. The author of this piece says, “All step therapy does is to ask if those drugs have been tried and were successful, or not, in treating a condition.” In fact, step therapy protocols go far beyond that, forcing patients to fail, in some cases on multiple medications. The appeal process is slow and frustrating to doctors and patients and delays treatment.

The article argues that step therapy is needed to hold down the costs of prescription drugs. Actually, studies have shown that while step therapy may provide short-term pharmacy savings for health insurers, it can result in higher overall healthcare cost. That’s because ineffective medications can lead to higher utilization of other medical services, even causing hospitalization on occasion.

The article also states that doctors are paid to prescribe certain drugs. That is clearly false and would be illegal. Doctors evaluate the patient and prescribe a drug based on clinical factors. We try very hard to get the right drug at the right time for the patient but are often frustrated by the insurance company’s refusal to pay the pharmacy for the drug.

Doctors are generally opposed to step therapy because of the negative impact we see it having on our patients. As a cancer doctor, I know that a delay in getting the right drug can give the cancer time to make the patient sicker.

The legislation proposed in New Mexico does not ban step therapy but simply puts stronger protections into place for our patients. We want to have transparency in the insurance company’s decision making. Let us understand if the choices of drugs made by the insurance companies are based on science or money.

Doctors want their patients to get the right prescription, when they need it. That’s why physicians, the American Medical Association and many other patient advocacy organizations are supporting two bills – Senate Bill 11 and House Bill 42 – up in the Legislature to fix this problem. We want to put patients before profits!

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