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PROVIDERS SAY STEP THERAPY ADDS TO THE COST OF LABOR AND SUBSEQUENTLY INCREASES OVERALL HEALTHCARE COSTS, WITH MINIMAL BENEFITS TO PATIENTS.
additional time-consuming burden, especially for patients with chronic diseases and cancers. Prescribing physicians and pharmacists say the immense amount of paperwork and phone calls required to satisfy the discrete policies of various payers and bene t plans take valuable time away from patients. In addition, payers take several days to respond to appeals and further delay appro- priate pharmaceutical treatment for patients. Providers also say step therapy adds to the cost of labor and subsequently increases overall healthcare costs, with minimal ben- e ts to patients.6 A major catch-22 for patients and their physicians—one that generates time consuming and costly appeals—involves one nebu- lous word: “ineffective.”
The Patient Experience
Around 2008, a patient experiencing debilitating pain was diagnosed with rheumatoid arthritis — the most common type of autoimmune arthritis. Her rheumatologist prescribed Orencia (abatacept, Bristol-Myers Squibb), a new generation of biologic anti-in- ammatory drugs that received FDA approval in 2005. Her insurance company refused to cover Orencia until she tried methotrexate, a far less expensive treatment. Although methotrexate helped slightly, she continued to experience chronic pain and limited movement. However, because she technically responded to the drug due to slight alleviation of pain, her insurance company refused to cover the cost of Orencia.
When the woman switched insurance companies, her doctor succeeded in attaining coverage for Orencia; once on the medicine, the woman said
her pain dropped to zero. She began hiking and living a normal life. But when the woman had to switch insur- ance plans yet again, her new insurer refused to cover Orencia unless she failed on methotrexate. She provided all documentation of prior experience to the new insurance company, yet they still denied it.11
On the ip side, patients with chronic diseases frequently rotate medicines due to changing symp- toms and accumulated toxicities. For example, psoriasis medications are known for causing renal problems and bone marrow suppression, and physicians frequently rotate their patient’s medications to limit or treat side effects. Yet rotating medications, though bene cial to patients, runs contrary to step therapy protocols.12
For oncology patients, step therapy adds more layers of complexity due to the side effects of chemotherapy and the aggressive nature of some cancers. A patient with lung cancer responded well to the chemotherapy drugs rst prescribed by her on- cologist. When her health stabilized, he gave her a “temporary break” from chemotherapy to relieve her
of some side effects. But when he tried to return her to treatment, her insurance company refused cover- age, saying the “temporary break” indicated the treatment had failed. Despite the oncologist’s protests, the insurer said the patient would have to “step” to another chemotherapy treatment, which represented only
a 5 percent response rate. As the on- cologist suspected, the patient did not respond, yet instead of allowing her to return to the rst chemotherapy cocktail, the insurer insisted she try another therapy rst. The patient ul-
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