Time for another appalling health insurance story. Today we’ll discuss an invention of theirs called Step Therapy, allegedly created “for your safety and to control health care costs.” It won’t surprise you that its real purpose is to generate massive revenues for their bottom line. Unfortunately, you, the patient, virtually always suffer unnecessarily in the process.
Doctors call Step Therapy the “fail first” policy. Let me explain. Step Therapy actually requires that before an insurer will authorize reimbursement for a medication your physician thinks will help you, your doc must document that he or she has first recommended other medications (either over-the-counter meds or cheap generics) from a health insurance industry-generated “approved list,” that they’ve been prescribed to you, and that they failed.
You can see why doctors call it fail first.
To give you an idea how appalling Step Therapy is for patients, the California legislature is in the process of banning the practice outright. You can believe the protests from the health insurance industry have been self-righteous and loud.
Here’s an example of how it all works. Let’s say you have fibromyalgia and I wish to write you a prescription for Savella, a brand-name drug that is FDA-approved for fibro. When you go to fill your prescription, if your insurer has Step Therapy in place, your pharmacist gets a “denial: prior authorization needed” notice from your insurer. The pharmacist then faxes this denial information to me. On it is an 800 number for me to call. After a series of deliberately annoying delay tactics (in order to discourage my writing this prescription in the future), I’m sent a list of medications I have to prescribe for you before they will authorize Savella.
Amazingly (or not so amazingly perhaps), some of the meds I am being forced to prescribe first are not even FDA-approved for fibromyalgia. If you had an adverse effect from one of them, in theory you could file a malpractice suit against me for prescribing an unapproved drug (I’m hopeful you wouldn’t). And yes, insurance companies know this but it doesn’t seem to faze them.
Generally the health insurer’s list of “approved” drugs contains inexpensive losers. I already know from first-hand experience that most of these drugs won’t work. Nevertheless, I’m compelled to write you prescriptions for two or more of them and you are required to fill the prescriptions before you can receive your Savella, the drug that in my judgment is most likely to help you. The insurance company hopes you’ll try the first of their cheaper approved drugs for a month or two, maybe feel a little better, and remain on it. If you return to me and report that the first medicine didn’t work, I have to prescribe you the second loser drug from their list.
For your insurer, a good scenario is that you’d get so discouraged by this whole process that you’d never bother to return for the Savella. Even better for the health insurer, you’d get laid off and lose your health insurance altogether (health insurers loathe fibromyalgia patients).
There is no requirement, however, that you have to swallow the insurer’s loser meds. Nor is a full month required between each to get all three prescriptions filled. Simply filling your first ineffective prescription enters you into the pharmacy computer system as having tried it. You can return the very next day, report the first drug gave you a headache, fill the second, and ditto come up with a reason it didn’t work. Then, on the third day, when you bring in your Savella prescription, the pharmacist can press “yes” when the denial question pops up (“Have any of the following medications been tried first?”) and by doing so your health insurer will cover the Savella.
Now when health insurance information systems started noticing people filling three prescriptions over three successive days, insurers smelled a trick. To counter this, they’ve recently added yet another form, two pages long and very detailed. It’s not their form, actually, but one from the FDA entitled “Mandatory Reporting of Unexpected Side Effects.” In a cover letter accompanying this form, the insurer warns, “For the safety of your patient, we will not authorize your prescription until you have completed this form and sent it to the FDA.”
It’s yet another step to trip us up in their profitable Step Therapy ploy, another delaying tactic to keep you from getting the medication I originally prescribed. They’re keeping their greedy fingers crossed that, finally pushed to the edge like this, frustrated physicians will throw up their hands and shout “I promise I will never ever prescribe this drug again!”
Actually, insurers know this sort of mandatory FDA reporting is utter nonsense. Doctors are required to report a drug side effect only if that side effect has never been reported by patients in the past, an event that almost never occurs. Standard side effects, like upset stomach, do not require FDA reporting. So doctors are now simply checking “yes” to the question on the pharmacy form “Did you report the side effect to the FDA?” and tossing the uncompleted FDA form into their shredders. By checking the “yes” box, the health insurance computers release your drug. Not having access to the FDA computer systems (yet!), the insurer has no way of knowing if the form was ever completed by the physician.
Sadly, your kindly pharmacist is likely in cahoots with all this. Few patients are aware that pharmacists receive a financial “incentive” (Chicagoans may be more familiar with the term kickback) every time they helpfully attempt to convert your more expensive brand-name drug to a cheaper, and possibly less effective, generic version.
Parenthetically, patients ask me all the time if generics are as good as name-brand versions. The answer is a straightforward “Generally, yes. Sometimes, no.” Certainly patients have reported lying awake at night waiting for sleep from their generic Ambien, felt anxious despite their generic Xanax, and wait uselessly for their migraine to clear with generic Imitrex. Branded drugs have been clinically tested on real people. Generic manufacturers need only complete a document saying the drug they’re producing is the same as the branded one. No clinical testing is required, and that’s why they’re so cheap. Most generic manufacturers are excellent–others, well, you never know.
The point of Step Therapy is not simply brand-drug-versus-generic, but rather your accessibility to new drugs versus being limited to older and often ineffective ones. In the field of clinical pharmacology, old is virtually never better.
If this all chicanery on the part of the insurance industry sounds like it should be illegal, with luck sometime in the next few weeks it will be in California, and in the next few years everywhere else as well. In the meantime, for your own sake…
David Edelberg, MD