Drug Costs

The Real Impact of Step Therapy

December 17, 2018 10:45 am

Last month, we explored step therapy and how it affects patients. Our post pales in comparison to this first-person account from rheumatoid arthritis (RA) patient Elizabeth Krempley.


As Krempley explains, RA is an “incurable, progressive, and ultimately crippling illness” that, for 15 years, caused “debilitating joint pain and inflammation” that left her exhausted and, at times, struggling to walk.


Today with treatment, Krempley leads what she calls a relatively “normal life.”


Krempley’s experiences with insurance companies, unfortunately, also are all too normal. Krempley explains insurers have tried to deny coverage of the drugs her doctors prescribed. While she trusted her doctors, Krempley said her insurance company did not, preferring instead that she try other, less-costly drugs first. Krempley not only was forced to take medications that didn’t work – she had to endure ones that, for her, caused difficult side effects. At other times, she “split pills and rationed medications, sometimes skipping doses for a day or two.”


According to the Arthritis Foundation, because of step therapy, RA sufferers on average are forced to try two or more different drugs because before getting the one their doctor originally wanted them to use.


Her insurance company’s decisions affected more than Krempley’s health. Her body deteriorated so profoundly that she was forced to drop out of college and move in with her parents.


Patient groups and physicians representing arthritis sufferers are not the only ones who oppose policies like step therapy. After the Centers for Medicare and Medicaid Services (CMS) announced its new step therapy policy in August, Dr. Jeff Vacirca, CEO of New York Cancer Specialists, explained, “Cancer treatment is becoming more personalized and not all therapies produce the identical result from patient to patient. Having therapy options is imperative to successful treatment.” He argued, CMS’ decision was “the antithesis of where personalized cancer treatment is going—it’s old school, cookbook medicine that treats every patient as one size fits all. It’s telling me to effectively sit back and let some middleman make treatment decisions for my patients.”


Krempley empathizes with Medicare patients who have been forced to endure step therapy. She says, “It’s a bad policy, lacking even the most basic safeguards to ensure that step-therapy policies are used appropriately.”


She recommends Congress pass legislation to end the use of step therapy in Medicare.


But this is a great example smart policy colliding with convenient politics. Critics of the biopharmaceutical industry, like Patients for Affordable Drugs founder David Mitchell, have rallied around step therapy as a way to lower drug costs. Mitchell, for example, acknowledged concerns about step therapy but also said he supports Medicare’s use of it. Last month Mitchell said, “if science says drugs are equally effective, I’m okay starting with the cheaper one.”


If only it were that simple. For starters, who determines effectiveness? In Krempley’s experience, her opinion and her doctors’ opinions meant far less than the opinions of the health insurance companies. And Mitchell’s comment ignores the painful process many patients endure to prove one treatment is more effective than others.


Step therapy might sound like a good idea in theory, but the consequences can be very damaging to the patients impacted by the recent push to expand this practice.