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OPINION: Step therapy is cost-based healthcare that may end up being more costly in the end

OPINION: Step therapy is cost-based healthcare that may end up being more costly in the end

By Ted Ryerson

The Easterseals mission for the past 100 years has been to ensure Americans living with disabilities are able to access the same opportunities as any other man, woman and child living in the United States.

Our work often requires us to explain that disabled individuals don’t live different lives. Like everyone else, we go to school, get married, work, have families, do laundry, pay our taxes and vote.

Also, like most Americans, every medical bill comes with anxiety, and too often they come with a fight over what is and isn’t covered. A rule implemented this year by the Centers for Medicare and Medicaid Services (CMS) would guarantee senior citizens with disabilities spend even more time wrangling with insurers.

Under the new regulatory scheme, Medicare Advantage plans could implement a process called step therapy for seniors who rely on prescription drugs paid for by Medicare Part B. These seniors are often some of the most vulnerable patients facing difficult health challenges, including cancer, autoimmune disease, and mental illness.

Insurance company step therapy protocols, sometimes called “fail first” requirements, mandate patients to try lower-cost drugs before accessing the more-costly treatments prescribed by their doctors. It is only when the medicine dictated by the insuring company fails (or when a lengthy appeals process is finished) that a patient can gain access their doctor first prescribed.

Trump administration officials argue the measure would ensure beneficiaries “pay less overall or per unit for Part B drugs.”

We believe it would seriously erode patients’ access to care, particularly patients with chronic conditions or who are disabled, and it could increase overall health care costs. One study of antihypertensive step therapy found costs rose because patients who had been forced to use step therapy were using the emergency room more and had been admitted to the hospital at higher rates.

Step therapy protocols vary by insurance provider. One insurer might require a patient to go through more steps before getting to his or her doctor’s preferred method of treatment. Another carrier might require the steps to be longer (e.g., a patient might need to stick with a treatment for more time). In other words, for a patient using company A it might take a few months to get through step therapy. For a patient using carrier B, it could take a year.

Prolonging ineffective treatment could result in increased disease activity, loss of function and possible irreversible progression of disability. One study found delays in treatment of three to six months for breast cancer patients were associated with a 12 percent lower five-year survival rate. Another study found rheumatoid arthritis patients who delayed treatment for four months experienced significantly more radiologic joint damage after two years when compared with patients who began treatment within two weeks.

Though the Trump administration new rule would affect only a certain number of seniors, it gives legitimacy to an idea that also has created nightmare scenarios for countless children and their families.

One young boy in Iowa who suffers from Asperger’s syndrome, asthma, attention deficit hyperactivity disorder and Gastroesophageal reflux disease was forced to try multiple generic drugs that didn’t work after his mother switched jobs and insurance plans. The new insurer didn’t consider that, under the family’s previous plan, the boy had already tried multiple treatments.

It’s because of stories like these that Easterseals has worked throughout the country to ensure that, if insurers are allowed to use step therapy, they do so in a way that affords patients some basic protections, like a speedy appeals process to challenge a denial of treatment.

To its credit, the administration recently announced some new guardrails for seniors who are now at risk of being harmed by step therapy. But the best outcome for all seniors is for the rule to be abandoned entirely so that vulnerable seniors who rely on prescription medicines can receive the treatment they need when they need it.

Tim Ryerson is president and CEO of Easterseals Tennessee.

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