Imagine you must take a trip, there is no option – you must go. You know exactly where you need to go, the route to take and what you will do when you arrive. What you can’t decide is how to get there − will you fly, take a train, drive yourself, ride a bike or even walk? Your mode of transportation will be decided for you.
That is the scenario health care providers are faced with every day when determining the best course of action in treating patients. After all the lab work, x-rays and assessments are completed and a diagnosis made, the real work begins. It seems the logical next step would be to prescribe the appropriate medication, therapy or treatment, but due to a cost saving protocol called “step therapy”, the first thing a provider must do after determining the diagnosis is to ask, “Who is the insurance carrier?” Because, this is where the mode of transportation from a state of disease to one of health is determined.
Under step therapy protocol, even when the provider has research and practice protocols to support the need for specific treatment, the patient may be denied coverage for that treatment until they have extinguished all the “steps”, or other treatments, by trying them, and failing, to have results. It can take months to go through all the “steps”, which can lead to disease progression and onset of other diseases.
During this phase, attempting to treat our patients turns into something akin to a scene out of the 1987 film, “Planes, Trains, and Automobiles.” It comes with complete with a detour at every turn, frustrating setbacks, irreversible damage and painful delays in recovery – leaving patients unsure if they will reach their destination of health, ever again. These experiences, however, are never a comedy for the patients, who are desperate to be healthy and functioning, yet required to wait while attempting multiple other treatments, only to fail, in order to attain the relief they so desperately need. During this process, time is not on their side.
For example, “Patient A” is a 54-year-old male, who when first diagnosed with Rheumatoid Arthritis did well on his initial medication but developed liver function problems, which are a known adverse effect of that drug. With this development came the need to discontinue the initial drug but because his disease was progressing, the next option in treatment was a biologic medication considered the standard of care to get Patient A functioning. As they say, this is when you should buckle up because it’s going to be a bumpy ride. His health care provider requested approval for the new drug, but it was denied by his insurance carrier. The denial was appealed to the insurance carrier but was met with a second denial that also included the requirement that he to stay on the medication that had caused his liver function problems. Another appeal was made and again, a third denial was received by his insurance carrier. With further debilitation, Patient A was placed on short-term disability and began to have secondary side effects from the steroids he had been using to alleviate the pain. A third appeal was made on his behalf and this time the medication was granted. He was then placed on the biologic drug originally prescribed and began functioning within three weeks. Unfortunately, because of his long-term steroid use while going through the step therapy protocol, he remains further challenged with insulin dependent diabetes.
Did you keep up with the long winding road that is “step therapy?” Treatment that allowed Patient A to be functioning was possible in only three weeks but due to the months of delays while following “step therapy” and “try and fail” protocols, he endured suffering and disease progression, remains on disability and now also battles insulin dependent diabetes. How is this a cost saving process to him, to the public or even to his insurer?
His body took a beating, his quality of life diminished and independence gone as he remains on disability and must look forward to life of not just one debilitating disease, but a secondary disease brought on by medications. All while waiting for what is widely known as the standard of care in treatment for his disease. And at what cost to this man did the insurance company save their money? At what cost to our society, when human capital is lost and lives are left in shambles?
We all agree, health care costs must be managed. But to overlook the word “health” in providing health care removes all purpose. Rep. Nancy Barto is sponsoring HB2420, which will establish transparency, efficiency and fairness in patient health care through necessary reforms to step therapy protocols. I encourage anyone who has ever been denied a medication that their physician or health care provider, in their medical expertise prescribed, to please follow this bill and thank Barto for her work.
Theresa Frimel is a nurse practitioner and a member of the Arizona United Rheumatology Alliance and Scope of Practice Committee at the State Board of Nursing. She is also with the American Association of Nurse Practitioners and the American College of Rheumatology.