Drug Costs

What is Step Therapy & How Does It Affect Patients?

November 29, 2018 1:25 pm

Just because something's expensive doesn't mean it's the best.” That statement, found on a health-insurance company website, is true. Just ask anyone who bought one of Money magazine’s 20 worst cars priced at $100,000 or more.


But while that statement is true, it doesn’t mean the idea insurers are selling – step therapy – is a good one.


Groups like Patients for Affordable Drugs tout step therapy as a way to reduce drug prices, but a growing body of research shows this idea doesn’t benefit patients at all.


Step therapy requires patients to take lower-cost treatments before they can move to medicine that might have a higher list price. Health insurers have long promoted the idea and, as Xtelligent reporter Sarah Heath explains in this article, when patients don’t go along, insurers deny the patient coverage.


The result, of course, is a lot of unnecessary pain and suffering.


Trial and error may be fine for a pair of running sneakers, a cable provider, or even an automobile, but applying the principle to health care is far more than troublesome. It’s perilous for patients with chronic illnesses who depend on a specific drug regime to stay healthy and, since the process isn’t used exclusively for patients with chronic illnesses, for some Americans it even can be deadly. As Heath wrote, “At best, the strategy delays care for patients, and at worst keeps patients from seeing their desired treatment altogether.”


Alliance for Patient Access Chair Dr. David Charles recently told CBS that he’s seen arthritis patients who have been forced to try less expensive, less effective drugs to control flare-ups. Those patients suffer from “pain, and worse, joint injury that may never be repaired.” Patients with multiple sclerosis have had the same issue and the same outcomes with step therapy, Charles said.


It’s because of situations like these that patient advocates oppose step therapy. For example, in April 2017, the American Society of Clinical Oncology said: “Step therapy policies are generally inappropriate in oncology due to the individualized nature of modern cancer treatment and the general lack of interchangeable clinical options. … Medically appropriate cancer care demands patient access to the most appropriate drug at the most appropriate time.”


As Heath noted in her article, insurers can slightly reduce costs by requiring step therapy, but “there is little evidence suggesting that any cost savings benefit the patient.” Heath also cited a 2010 study that found that, while insurers saved money, “total healthcare costs remained the same or increased.” That study also found patients spent hours navigating the step process and “the time spent resolving barriers to drug access [led] to delays in medication use and additional costs to patients.”