As science makes once-unthinkable treatments available, patients are increasingly facing a harsh reality: Insurance companies are forcing them to try older, less expensive therapies for months before covering pricier ones.
Insurers have long relied on a cautious approach to control costs and spare patients from expensive medications they might not need. But in more than a dozen interviews with doctors and patients, a picture has emerged of insurers growing more aggressive as they respond to financial pressures.
The result is a reliance on what is known as “step therapy,” whereby patients are forced to try cheaper treatments before they graduate to more expensive ones, even when health care providers are confident the inexpensive treatments will not work.
In one example, a woman with lupus said her vision was severely affected after an insurer forced her to try multiple medications before paying for one that her doctor initially wanted to prescribe. In another, a patient with lung cancer took a break from a successful chemotherapy regimen, then was blocked by her insurer from resuming it until she had tried other drugs.
Spurred by stories like these, state legislators, who regulate Medicaid plans and much of the nation’s private insurance, have begun pushing back. In recent months, at least five states, including California and Indiana, have passed legislation to rein in step therapy approaches, known by critics as “fail first” policies. More than a dozen other states now have such laws on the books.
Insurers argue that, beyond individual patient cases, step therapy has improved their ability to cover a wide range of patients and medications.
“Step therapy is addressing the problem of making sure patients get the right treatment at the right time, and if there’s an affordable alternative, they have access to it first,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group.
Doctors and ethicists generally do not dispute that theory. Dr. Steven D. Pearson, founder of the Institute for Clinical and Economic Review, a health care industry think tank, said that in situations in which two treatments would likely offer equal benefits, “most people would say it’s reasonable to try the less expensive one first.”
But “the important nuance comes when there might be specific reasons where a patient or doctor feels like the more expensive drug would work better,” he said. “So it all depends on what the harm would be if they tried the less expensive one first.”
The rise in step therapy policies is being driven by a host of factors, including rising drug costs. Employer-sponsored health plans are growing more restrictive with coverage, analysts said, as businesses seek to control healthcare spending. Participants in Affordable Care Act health care exchanges have also been affected: Many patients have switched carriers, either by choice or because insurers have exited the exchanges. When they do, patients are often told to restart step therapy protocols anew.
“The patient’s being told to use a drug we know isn’t going to work, but we have to use it anyway for someone with terminal illness? To me that’s just insane.”
Dr. Kenneth B. Blankstein, oncologist
Take Karin Keyes, a 45-year-old psychotherapist on Long Island. Keyes was diagnosed with rheumatoid arthritis roughly eight years ago while enduring excruciating pain.
Her doctor prescribed Orencia, one of an expensive new generation of so-called “biologic” anti-inflammatory drugs that can cost as much as $50,000 annually.
Keyes’s insurer at the time said it would not cover Orencia unless she tried methotrexate, a far less expensive treatment. Methotrexate helped slightly, but Keyes was still in pain and had limited movement. Still, because she technically responded to the drug, she didn’t qualify for Orencia.
When she changed to a new insurer, her doctor prescribed Orencia again, this time with success. “My pain went to zero,” Keyes said. “I started hiking, living a normal life.”
It was not a permanent solution. When that insurer filed for bankruptcy protection earlier this year, Keyes’s new insurer said it would not cover Orencia unless she failed on methotrexate again.
“They had all the documentation. They’d seen that I’d not done as well on methotrexate,” she said. “They still denied it.”
Doctors and patient advocacy groups said insurance companies often insist on step therapy regardless of past medication failures. For some patients, though, one trip through the process can bring significant risks and strain.
Kathleen Arntsen, of Verona, N.Y., said her ophthalmologist prescribed Travatan Z eye drops in 2014 to treat glaucoma because he feared that other medications might trigger side effects and because her eye responded well to samples of the medication.
Arnsten’s insurer said she would have to try two cheaper drugs first. Over the course of seven weeks, those medications led to “massive” swelling and pressure, she said.
At the end of the span, the insurer approved Travatan Z, but her vision continued to deteriorate. She is blind in that eye, and is considering having the eye removed because of persistent pain.
Arntsen, who has advocated for step-therapy regulations in New York, said she and her doctor cannot say for sure whether the delay caused her vision loss, but she believes it was a contributing factor.
“I’m an educated advocate, and my doctor didn’t give up on this, yet I was forced to fail a treatment he predicted I’d fail on,” she said.
Pearson, of ICER, said there’s no effective way of determining how well or poorly insurers are handling step-therapy disputes with doctors and patients. In a 2014 Health Affairs report he coauthored Rahul Nayak, Pearson set forth some ethical guidelines for fairly applying step therapy.
Chief among them: clearly define failure; don’t cause long-term harm; rapidly review relevant new evidence in developing step-therapy guidelines; and give doctors quick and easy ways to appeal an insurer’s decision.
J. Russell Teagarden, a health care industry consultant with experience in setting drug coverage policies for health insurance plans, said the last recommendation in particular is “very difficult” to follow because the complexity of many cases means it takes time and medical specialists to resolve them.
Teagarden, a former executive at the pharmacy benefits management company Medco Health Solutions, which was acquired by Express Scripts in 2012, said that step-therapy policies and decisions “would keep us up at night. It’s a big job to stay on top of. It requires people and a lot of money and not every company can do it. It’s a real issue.”
Some insurers, he said, “play games with these things, and put them in place simply because it’s a barrier. They’re looking for attrition. No one will admit it, but that’s the case. And shame on them.”
Patients’ frustration is shared by doctors, who have grown accustomed to — but no less frustrated by — the insurance industry’s efforts to contain costs. Sometimes the insurer’s step-therapy decisions perplex doctors.
Dr. Kenneth B. Blankstein, an oncologist in Flemington, N.J., is treating a woman for lung cancer. She responded well to the first chemotherapy drugs he prescribed. When her health was stable, he gave her a “temporary break” from chemo to spare her some of its side effects.
But when he tried to return her to the treatment, the insurer balked, saying that the “temporary break” was evidence that the treatment had failed. Despite Blankstein’s protests, the insurer said she would have to move next to Tarceva, another treatment.
“She had under a 5 percent chance of a response on Tarceva,” he said. “Yet they insisted, so we had to.”
As Blankstein expected, the patient did not respond, but instead of letting her return to the first chemo cocktail, the insurer insisted she try another drug first.
The patient ultimately switched to Medicare, which covered the first chemotherapy protocol. Her health is stable.
“The patient’s being told to use a drug we know isn’t going to work, but we have to use it anyway for someone with terminal illness? To me that’s just insane, but it’s the way they do things,” Blankstein said. “It’s taken away clinical judgment. It’s managing by algorithms.”
State laws restricting the practice of step therapy vary widely.
According to the National Patient Advocate Foundation, a nonprofit group, Indiana’s law is the most aggressive. Among other things, it bars insurers from restarting the step-therapy sequence if they had already failed certain treatments with a previous insurer, and insurers must adjudicate appeals within three days.
Advocates said that patients in other states will do well to review the step-therapy policies of prospective insurers before signing up. Larger insurers will often post lists of drugs that are subject to step-therapy restrictions, but sometimes even those restrictions can vary based on a particular employer’s health plan, for instance.
“Step therapy can have a place in a reasonable plan design,” said Alan Balch, chief executive of the National Patient Advocate Foundation. But that plan should be transparent to patients and allow for appeals, he said. “There is no humane reason to deny a patient access to a therapy that has the best chance of curing them.”