This is a process called step therapy, where insurance companies can dictate to the doctor and patient which medications they will elect to cover. Perhaps more incendiary, insurance companies don't allow patient history with other payers to affect their policy. Gary had already tested the less expensive drugs when he was covered under a different insurance company and those tests failed, but his new insurance company was inflexible and required Gary to go through the process again.
Step therapy can be a dangerous and inhumane practice because it forces patients to go undertreated (or even untreated) while insurance companies essentially experiment with medications. Throughout the process, patients find themselves as unwilling guinea pigs. Step Therapy replaces physicians' judgment and often compromises patient care, which is ironic since most physicians would elect to use less expensive medications as long as they were both safe and effective. In sum: Step therapy enables insurance companies to practice medicine on the basis of cost, not effectiveness, of drugs.
When patients are forced to discontinue a drug that successfully treats their condition, the outcomes can be disastrous. What Gary experienced is similar to what happens daily to thousands of patients who have no recourse, which is what Rep. Eric Hutchings' HB 266 attempted to correct in the recent Utah Legislative session. The bill would have prohibited the use of step therapy for pharmaceuticals unless certain conditions were met. Unfortunately — and tragically for many people negatively affected by Step Therapy — our Utah State Legislators did not agree, and the bill failed to become law.
Step Therapy can have lethal consequences. For example, naloxone is an anti-overdose medication that is used to reverse the effects of opioids such as heroin. There are several different naloxone products available, and some are more expensive than others.
As I've said, step therapy allows payers to refuse to pay for the more expensive antidotes unless a person fails the less expensive product. However, demonstrating a drug's "failure" in this scenario means that the patient has to fail to be resuscitated; if there is a failure of reversing an overdose, the person dies, and there is no opportunity to appeal for a more expensive antidote.
Step therapy may make sense fiscally for insurers, and yielding to the wishes of insurers may have made political sense for our legislators. However, tabling House Bill 266 makes no sense at all to the chronically ill patients who had hoped for more compassionate treatment by their lawmakers and insurers.
As a physician and researcher who has dedicated more than three decades to becoming an expert in the field of pain and addiction medicine, I am profoundly disappointed that the Utah legislature feels that insurance companies are more qualified than physicians to determine the most appropriate therapy for their patients.
My heart goes out to those living in chronic pain who must endure step therapy, and I hope that they will soon find the pain relief that they require for a life worth living.
Lynn R. Webster, M.D., is a past president of the American Academy of Pain Medicine; vice president of scientific affairs at PRA Health Science, and author of an award-winning book, "The Painful Truth" (Oxford University Press).