As a rheumatologist in practice now for almost 25 years, I’ve been fortunate to see medical science provide us with even better medications for people with rheumatoid arthritis, lupus, psoriatic arthritis, and vasculitis. The newer medications are life changing, and we see improved outcomes in terms of joint damage, overall health and survival for people with these difficult conditions.
The decision for what medication to use and when to use it is based on the patient’s medical condition, his or her history and myriad other factors that are based on a deep knowledge of the drugs, condition and patient preferences and goals. Only the physician and the patient know what choice will be best for that patient.
However, after my patient and I make that decision, my next question is always, “What insurance are you covered by?” This question should be irrelevant in our discussion, but with step therapy, it is not. Step therapy is dictated by what medications an insurer covers, not a patient’s medical condition or a physician’s advice.
Most of the time, I know I am in for a fight to get the right medication for my patient. I devote a great deal of resources to that fight, and it has very serious consequences for some patients: delays in proper care, extra costs for additional medications and office visits, and in the worst, cases a deterioration of their condition. My staff and I spend some time every single day fighting with insurance companies to get patients on the right medication or keep them on drugs that are already working for them.
Recently, a woman with refractory Rheumatoid arthritis told me the medication she is on had stopped working for her and that she's feeling daily pain and swelling in her joints. This was the fifth medication to fail for her. After discussing the risks and benefits of the remaining options, we chose what we felt was best for her — and were met with a rejection letter stating that because she hadn't tried every single medication of a given type, she wasn't cleared to try a different type and that the drug we had chosen was not approved for rheumatoid arthritis.
That is the kind of nonsense that aggravates well-meaning doctors and the patients they serve, leaving them feeling this entire process is a game where the only aim is to benefit the insurance company, rather the health of the patient. Denials and steps are not based on solid medical evidence. They hinder our care and can worsen a patient’s condition. Step therapy is being used as a blunt instrument to limit access. It is restricting physicians' discretion and interferes with the practice of medicine. Most importantly, it hurts patients.
The indiscriminate use of step therapy has to change. I support Senate Bill 680/House Bill 1464, which aim to reform the practice and make it more focused on the patient — where all good medical decision making should be.