Are insurance policies saving patients money, or keeping them from the treatment they need?

As science makes the once unthinkable treatments available, patients increasingly they face a harsh reality 😕 Insurance companies are forcing them to try less costly for the month before covering the most expensive older therapies.

Insurers have long relied on a prudent approach to control costs and patients parts of costly drugs that may not need. But in more than a dozen interviews with doctors and patients, a picture has emerged of insurers grow more aggressive as they respond to financial pressures.

The result is a dependency of what is known as “ step therapy ,” whereby patients are forced to try cheaper treatments before graduating to more expensive, even when providers of healthcare rely on expensive treatments will not work.

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In one example, a woman with lupus said his vision is severely impaired after an insurer forced her to try several medications before paying for one your doctor initially wanted to prescribe. In another, a patient with lung cancer took a break from a chemotherapy regimen successfully, then was blocked by your insurer resume until she had tried other drugs.

Spurred by stories like these, state legislators, governing Medicaid plans and most private insurance in the nation, have begun pushing back. In recent months, at least five states, including California and Indiana have passed laws to control approaches step therapy, known by critics as “a first test “policies. More than a dozen other states now have such laws on the books.

Insurers argue that, beyond individual cases of patients, step therapy has improved its ability to cover a wide range of patients and medications.

“step therapy is addressing the problem of making patients receive the right treatment at the right time, and if there is an economic alternative, which have access to it first,” said Clare Krusing, a spokeswoman of US health insurance plans , a trade group.

Physicians and ethicists generally do not dispute that theory. Dr. Steven D. Pearson, founder of Institute for Clinical and Economic Review a health industry think-tank said that in situations in which two treatments would probably offer the same benefits, ” most people would say it is reasonable to treat the least expensive first. “

However,” the important nuance comes when there may be specific reasons in which a patient or physician feels like the more expensive drug would work better, “he said. “So it all depends on what would be the harm if the least expensive was first tried.”

Increased political step therapy is being driven by a number of factors, including increased drug costs. health plans sponsored by employers are increasingly restrictive coverage, analysts said, as companies seek to control health spending. Participants in the Act exchanges Affordable health care assistance have also been affected: Many patients have changed supplier, either by choice or because insurers have left the trade. When they do, patients are often told to restart step therapy protocols again.

“the patient being told to use a drug that we know will not work, but we need to use anyway for a terminally ill person? To me that’s crazy “.

Dr. Kenneth B. Blankstein, oncologist

Take Karin Keyes, a psychotherapist 45 years old, on Long Island. Keyes was diagnosed with rheumatoid arthritis about eight years ago while enduring excruciating pain.

Your doctor prescribed Orencia, one of a new generation of expensive-called “biological” anti-inflammatory drugs that can cost as much as $ 50,000 annually.

Keyes insurer at the time said it would not cover Orencia unless she tried to methotrexate, a much less expensive treatment. Methotrexate helped a little, but Keyes was still in pain and had limited movement. Still, because technically responded to the drug, which did not qualify for Orencia.

When switching to a new insurer, your doctor prescribed Orencia again, this time successfully. “My pain went to zero,” Keyes said. “I started to walk, to live a normal life.”

was not a permanent solution. When the insurer was declared bankrupt earlier this year, the new insurer would not cover Keyes said Orencia unless she failed again methotrexate.

“They had all the documentation. They had seen that I had not done so well in methotrexate” he said. “I still denied.”

Karin Keyes
Alice Proujansky for STAT Keyes, a psychotherapist 45 years old, has a dose of your medicine against arthritis.

Doctors and patient advocacy groups said that insurance companies often insist on step therapy regardless of past failures medication. For some patients, however, a trip through the process can bring significant risks and strain.

Kathleen Arntsen, Verona, NY, said his ophthalmologist prescribed Travatan Z eyedrops in 2014 to treat glaucoma because he feared that other medications can cause side effects and because his eye responded well to samples medicine.

Arnsten insurer said it would have to try two cheaper drugs first. Over seven weeks, the drugs led to “massive” swelling and pressure, he said.

At the end of the period, the insurer approved Travatan Z, but his vision continued to deteriorate. She is blind in that eye, and is considering the possibility of having the eye removed because of persistent pain.

Arntsen, who has advocated for the rules-step therapy in New York, said she and her doctor can not say for sure if the delay caused loss of vision, but is believed to be a contributing factor.

“I am an educated advocate, and my doctor did not give up on this, however, was forced to fail treatment predicted would fail on,” she said.

Pearson, ICER, said there is no effective way to determine how well or poorly insurers are handling disputes-step therapy to physicians and patients. In a 2014 report co-authored Health Affairs Rahul Nayak, Pearson establishes some ethical guidelines for the fair application of step therapy.

The principal of them: clearly define failure; not cause long-term damage; quickly review new relevant evidence in developing guidelines step therapy; and give physicians a quick and easy way to appeal the decision to form an insurance company.

J. Russell Teagarden, a consultant care industry experienced health policies in establishing drug coverage for health insurance plans, said the latest recommendation, in particular, is “very difficult” to continue due to the complexity of many cases means and medical specialists time is needed to solve them.

Teagarden, a former company executive management pharmacy benefit Medco Health Solutions, which was acquired by Express Scripts in 2012, said that the policies and decisions of step therapy “we lose sleep. It’s a great job to be aware of. it requires people and a lot of money and not all companies can do. it is a real problem. ”

Some insurance companies, he said, “play games with these things and put them in place, simply because it is a barrier.’re Looking for wear. No one will admit it, but that’s the case. And the . shame on them “


patients’ is shared by doctors, who have become accustomed to – but no less frustrated – the efforts of the insurance industry to contain costs. Sometimes, decisions on the step therapy perplex medical insurance.

Dr. Kenneth B. Blankstein, an oncologist at Flemington, N.J., is treating a woman for lung cancer. She responded well to chemotherapy drugs first prescribed. When his health was stable, he gave a “temporary break” of chemotherapy to avoid some of the side effects.

But when he tried to take her back to treatment, the insurer resisted, saying the “time jump” was evidence that the treatment had failed. Despite protests Blankstein, the insurer said it would have to go next to Tarceva, another treatment.

“I was under a 5 percent chance of a response on Tarceva,” he said. “However, he insisted, so we had to.”

Blankstein As expected, the patient did not respond, but instead of letting his return to the first cocktail of chemotherapy, the insurer insisted to try another drug first.

Finally, the patient changes to Medicare, which covers the first chemotherapy protocol. His health is stable.

“the patient being told to use a drug that we know will not work, but we need to use anyway for a terminally ill person? To me that’s crazy, but it’s the way do things, “Blankstein said. “He has removed the clinical trial. It is management by algorithms”.

state laws restricting the practice of step therapy vary widely.

According to the National Foundation Patient Advocate a nonprofit group, Indiana law is the most aggressive. Among other things, it prohibits insurers restart the sequence of step therapy if certain treatments had already failed with a previous insurer, and insurers must adjudicate appeals within three days.

advocates said patients from other states would do well to review the policies of step therapy of potential insurers before enrolling. Larger insurers often publish lists of drugs that are subject to step therapy restrictions, but sometimes even these restrictions may vary depending on the health plan of a particular employer, for example.

“step therapy may have a place in a reasonable design plan,” said Alan Balch, executive director of the National Foundation for Patient Advocacy. But that plan must be transparent for patients and allow the appeal said. “There is no human reason to deny access of patients to a therapy that has the best chance of curing them.”

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