The Providence Journal recently published an article by Brittany Ricci, a student at Brown University’s Alpert Medical School, detailing her year-long struggle to receive the treatment her doctor had prescribed for a severe case of Crohn’s disease.
What is Step Therapy?
Another name given to step therapy is “fail first”. Health insurers developed the process in order to save money. The practice is allegedly intended to provide the safest and most cost-effective drugs before moving on to a costlier and perhaps riskier drug. But does it? And do they?
Brittany explains where this theory failed her. While waiting for approval of her prescribed medication, she underwent two operations and endured many trips to the hospital with other complications.
Brittany had been on medication for occasional symptoms of ulcerative colitis for many years but it was not until her freshman year at college that the disease became apparent.
As Brittany says, this is not the most ideal disease to have when using bathroom facilities shared by thirty other girls. She had developed an infection near her colon but after additional tests, the final diagnosis was Crohn’s disease.
As the disease progressed, Brittany found it painful standing, sitting and walking. Her doctor decided she needed a more aggressive treatment plan because her current medications were definitely not effective.
A new treatment plan was put into place but her insurance company denied coverage. That is where step therapy comes into play. One or more medications must “fail” before she would be approved for the medication that her doctor believes would alleviate her symptoms. In addition, her insurance company must select her second medication.
Brittany expressed disbelief at this scenario. As a medical student, she saw that there was scientific evidence proving that the medication her doctor had recommended was far superior to other medications in that category.
Her article was a call for lawmakers to act against step therapy. Brittany feels that insurance companies should not be able to select ineffective treatment plans for patients. She wants to ensure that doctors and their patients are the determining factors in selecting appropriate treatment.
A Bill As A Remedy
Brittany reports that a bill has been introduced in the Rhode Island General Assembly that adds several provisions to step therapy. The bill would negate fail first and clinicians will be able to determine which medication would be most beneficial to the patient.
Set time frames would apply to avoid waiting for approval and thus protect the patient from prolonged disease progression. The bill is patient-centered and fosters evidence-based medicine.
Brittany cannot help but think about the year she had to wait for the insurance company’s approval. Although her health has improved, she still has to deal with its repercussions. She keeps asking if it was necessary for her to suffer so much just to be approved for medication that had been prescribed months earlier.