Balancing great patient care with cost management is perhaps the biggest challenge in today’s health care system. One tool used by government and private insurance plans alike to try to limit costs is known as “step therapy.”
Under this practice, insurers will sometimes require a patient to try other, more common medications before approving the one a doctor prescribes. The hope is that the patient will respond to less expensive medication without the need for more specialized, more costly treatment.
But “step therapy” is dictated by medications an insurer covers, not a patient’s medical condition or a physician’s advice. As a result, it can have 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.
Assembly Bill 374 by Assemblyman Adrin Nazarian would help strike the proper balance between patient care and effective cost management.
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AB 374 would ensure that step therapy is appropriate and that patients aren’t forced to go through unnecessary steps. For example, if a patient has already tried the alternative, less-costly medication, their doctor should be able to recommend that they not go through another trial of that or a very similar medication again. If enacted, the bill would allow the patient and their doctor to seek an override of the insurer’s decision for step therapy.
There are different ways of treating arthritis, but one thing is certain: Until there is a cure, prescription drugs are often the main, if not only, way to treat the condition. This bill would help to ensure arthritis patients gain faster access to the medications they need.
As we’ve learned through years of research, while step therapy can control costs, its indiscriminate use can worsen a patient’s condition or even cause irreversible damage. Patients and physicians should have a bigger say in determining the proper course of treatment.
Dennis M.P. Ehling is Pacific region board chairman of the Arthritis Foundation.