Greetings patient advocates!

Imagine you and your doctor have found a biologic therapy that helps you manage your rheumatic disease symptoms and maintain quality of life.

Now imagine your insurance company won’t cover the therapy until you try – and fail – an “insurer preferred” therapy option first.

For many patients, this is the frustrating reality of a practice known as step therapy.

What is step therapy?

Step therapy – also known as “fail first” – is a utilization management technique employed by a majority of public and private health insurers that forces patients to try therapies preferred by the insurance company before being approved for the therapy their doctor prescribed – even when doctors doubt the “insurer preferred” option will be sufficient.

Step therapy can be painful and very dangerous to patients. Drug treatment regimens must be carefully tailored to the individual patient, and often a patient must try several therapies before being approved for preferred treatment – even when doctors think that option won’t be effective, or will cause side effects.

Meet a Patient Advocate

Rheumatology advocates visit Capitol Hill
Erin is second from the right – photo taken at a Capitol Hill briefing

I met Erin Vago, a juvenile arthritis patient, at a 2018 Capitol Hill briefing to advocate for arthritis research funding. She’s also an advocate for limiting step therapy because of her experience. Here is part of Erin’s story.

The day before I was to have my first infusion, I received a call that insurance was denying my usage of this drug because I hadn’t been on another drug [first]… I had to travel back down the drug ladder to try yet another drug that was a self-injection drug that is very painful when administered. Unfortunately, this new biologic had a three-month trial period and only a 50% chance of working for me. Neither my doctor nor I am very optimistic that 50% is enough for it to work, so the next three months will be a time of watching and waiting. This does not bode well for my other diagnoses.

What can we do about step therapy?

The Restoring the Patient’s Voice Act, introduced by Congressman Brad Wenstrup (OH-2), would place reasonable parameters around the use of step therapy. This bipartisan, common-sense legislation provides a clear and transparent process to seek exceptions to step therapy review by health insurance plans, and also establishes a reasonable and clear timeframe for override decisions. Importantly, before a health plan can delay or outright deny a patient’s ability to access a medically necessary treatment, the bill requires insurers to consider the patient’s medical history, take into account the provider’s expertise in partnership with his/her own patient, and respect the health care provider’s professional judgment.

You can take action today – contact your Members of Congress and ask them to support this common-sense legislation. By doing so, we can help make sure we are putting patients – and their health and wellbeing – first.

Dr. Angus Worthing