Insurers want to be penny-wise and pound-foolish with drugs

Summer is approaching and families are starting to make their vacation plans. For some families, it’s an annual tradition to go through this exciting process. For others, there’s more to it.

Families with loved ones who live with arthritis have much more to consider – it’s such an uncertain disease that can progress in unpredictable ways. Thankfully, for patients like me living with rheumatoid arthritis, medications have been developed that can dramatically improve quality of life. Access to these medications can make activities like summer travel and vacationing much more pleasant instead of a burden.

Access to vital medications means the difference between remaining an active member of society or having difficulties getting out of bed. However, accessing the medications patients need is getting more difficult these days.

Step therapy, or fail first, is a growing health insurance industry practice intended to cut costs. It requires patients to try and fail medications the insurer dictates before they will cover medications originally prescribed by their doctors.

According to the Journal of Managed Care Pharmacy, nearly 60 percent of commercial insurers were using step therapy in 2010. As of 2013, 75 percent of large employers reported offering employees plans that used step therapy.

If policymakers do not take steps to protect patients, it will only get worse.

Insurers argue that step therapy lowers health care costs while maintaining or possibly improving care quality. However, data clearly shows that step therapy can have the opposite effect.

In a study comparing spending on schizophrenia medications in Georgia’s Medicaid program, step therapy saved the state $19.62 per member per month in atypical antipsychotic expenditures.

However, according to a study by the University of North Carolina, School of Pharmacy, these savings were “accompanied by a $31.59 per member per month increase in expenditures for outpatient services.”

As a result, step therapy did not have the intended effect of reducing overall costs; rather, it increased health care costs. Similar findings have been found when applied to blood pressure medication.

Nor do these costs account for needless suffering by patients not being given the medicine prescribed by their doctor.

In addition, step therapy can delay access to optimal therapy, causing patients to unnecessarily experience disease progression. And some patients, so overwhelmed by the burdens they have to endure just to get the medications their doctors prescribe, simply give up and stop their treatment entirely.

Good patient/doctor relationships, especially with chronic illnesses, are vital for effective treatment and should not be hindered.

As of now, insurers can implement step therapy protocols as they wish. But it doesn’t have to be this way. The state of New Mexico can establish protocols that allow for exceptions to step therapy. This would include situations when a required drug is medically inadvisable, has been tried and failed previously, will not be effective, or the patient is already stable on another drug.

New Mexico should establish these basic protocols to ensure that step therapy does not harm patients.

You can do your part by letting the New Mexico Office of Superintendent of Insurance and your elected officials know about the importance of protecting patients’ rights by addressing the practice of step therapy and protecting the sanctity of the provider/patient relationship.

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