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Critics of Step Therapy Warn It May Lead to Worse Health Outcomes

Posted on January 05, 2022
See how 189 members reacted on this article
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Elizabeth Wartella, M.P.H.

  • On a recent podcast, representatives of the National Psoriasis Foundation (NPF) and Hemophilia Federation of America (HFA) discussed step therapy, a health insurance practice designed to reduce treatment costs.
  • Through step therapy, a person must first try a less-expensive medication selected by their insurer before using one recommended by their doctor.
  • Step therapy can sometimes lead to worsened symptoms or irreversible harm when people take an insurer-selected treatment that’s not effective.

People prescribed expensive treatments for psoriasis or psoriatic arthritis (PsA) may first need to try a less-expensive treatment option selected by their insurance provider, due to a practice called step therapy. In a recent episode of HFA’s podcast “The BloodFlow,” representatives of the NPF and HFA warned of the potential drawbacks of step therapy, including worse health outcomes for people required to delay getting their doctor-recommended treatment.

“We’ve heard from folks from the [psoriatic disease] community who have ended up in the emergency room, or needed additional doctor’s visits, or medical treatments that were otherwise preventable because step therapy stood between them and the treatment and relief that they needed,” said Hannah Lynch, a government relations specialist at the NPF, during the episode.

Joining Lynch was Lindsay Cox, a policy manager at the HFA. During the podcast, the two discussed step therapy and how it affects people with chronic conditions like hemophilia and psoriasis. Both the HFA and the NPF advocate for changes to the practice of step therapy.

What Is Step Therapy?

Sometimes referred to as fail-first therapy, step therapy is a health insurance practice designed to save money on treatment for chronic diseases. With step therapy, insurance companies require that someone first tries a less expensive medication selected by the insurer before covering certain medications.

Only after a person fails on the insurer-selected medication — meaning that the medication either doesn’t work or it worsens the person’s condition — will the insurance company cover the drug treatment initially recommended by a health care professional.

Delayed Access to Effective Treatments Can Be Harmful

During the podcast, Lynch explained that delayed access to treatment due to step therapy is a primary concern for people with psoriasis or psoriatic arthritis. She described how doctors work closely with people with psoriasis and other chronic conditions to determine treatments that will be the most effective — but also the safest, given that person’s medical history, allergies, and other medications and health conditions.

For people with conditions such as psoriasis and hemophilia, trying a medication that wasn’t prescribed by a doctor could present the risk of side effects and serious outcomes, including irreversible disease progression or death.

“We’ve seen examples of folks with liver disease … and they have been required through step therapy protocols to take a drug that may have severe side effects that include damage to the liver. Obviously a doctor would never prescribe that for their patient because it doesn’t make sense for their medical history and it puts them at greater risk,” said Lynch.

Step Therapy May Increase Costs

Although the purpose of step therapy is to save money, the practice may actually be more expensive in the long run, both for a person receiving care and their insurance company. According to Cox, these increased costs result from the delays a person experiences in accessing their doctor-recommended treatment. Extra costs “could include additional doctors visits, hospitalizations, extra use of certain factors, and permanent injury or even death,” said Cox.

What’s Next?

More than 20 states have created protection policies to safeguard people from step therapy. There are also advocacy efforts underway at both the HFA and NPF to support passing a federal bill called the Safe Step Act, which creates ways for people to be excused from step therapy.

The NPF’s Action Alert Center offers additional information about the Safe Step Act and the opportunity to send a letter to Congress showing support of the legislation. Resources for navigating step therapy and insurance while living with psoriasis are available at the NPF’s Patient Navigation Center.

Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Elizabeth Wartella, M.P.H. holds a masters in public health from Columbia University and is passionate about spreading accurate, evidence-based health information. Learn more about her here.

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