Physicians, not step therapy, should have final say in treatment, poll finds

By John Murphy, MDLinx
Published October 5, 2017

Key Takeaways

About seven out of 10 people oppose health insurance “step therapy,” and 95% of people agree that a physician—not an insurance company—should make the final decision on a patient’s treatment, according to a Michigan-area poll initiated by the American Autoimmune Related Diseases Association (AARDA).

Health insurance plans describe step therapy (also called a “fail first” policy) as a cost-saving effort in which a patient must first try (and fail) the least expensive treatment option before the plan will pay for the more expensive drug that the physician originally prescribed.

“Forced step therapy delays access to necessary treatments and can cause diseases to progress. Patients need the right medication when a doctor prescribes it,” said Virginia Ladd, President and Executive Director of AARDA, headquartered in Detroit, MI.

The issue is of particular concern for patients with autoimmune diseases and their providers. Although studies have shown step therapy can provide cost savings for certain common conditions when multiple therapeutically similar treatment options are available, that’s not necessarily the case for less common conditions such as autoimmune diseases.

One study on treatment of immune disorders found no meaningful cost-saving (or other) benefit with step therapy. “Adding a forced step therapy policy in this environment may simply delay a provider’s therapy choice, supplying suboptimal care and incurring any added expense a delay in the preferred treatment might cause,” the authors wrote.

“We need to put an end to this practice now,” said Ladd. “Step therapy risks patient health, undermines the expertise of doctors and their relationships with patients, and contributes to financial waste in our health care system despite insurers touting it as a cost-saving measure. It should only be used when a doctor decides it’s best.”

According to the AARDA poll, 98% of respondents said that doctors should have the final decision on treatment for a patient with an autoimmune disease when the doctor and insurance company disagree. The poll, conducted by Lake Research Partners on behalf of AARDA, was a telephone survey of 500 healthcare consumers throughout Michigan.

Other notable poll results:

  • 72% of respondents strongly favor insurance companies being required to allow medications to be "dispensed as written" by the patient’s doctor.
  • 76% strongly believe step therapy decisions should be based on guidelines developed by physicians.
  • 78% strongly support the idea that physicians should be able to override step therapy if they expect the treatment to be ineffective.
  • 91% of respondents agree that when physicians (not insurance companies) make the final treatment decisions, it has a positive effect on patients’ health. Two-thirds of respondents say this will reduce the amount of waste in the system, and more than half say it will help reduce costs.

In addition to releasing these poll results, AARDA also launched a statewide consumer education initiative, Let MI Doctors Decide (www.letmidoctorsdecide.org), which aims to help patients navigate the step therapy process and, if necessary, appeal insurance company decisions.

Meanwhile, numerous bills have been introduced in several states that seek to limit step therapy. Many of the bills call for health insurance companies to incorporate clinical review criteria in their step therapy policies, and provide a process for physicians to override the step therapy protocol.

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