This article in today’s Utica Post- Dispatch highlights the impact of the
Governor’s signing of the Step Therapy legislation. It also discusses the
role of consumer advocates like Kathleen Arntsen using her personal
experience with Lupus to advocate for a strong step therapy bill across all
disease states. A rapid appeals process with stronger input from
prescribers will help to minimize some of the negative consequences of
New law helps patients, doctors sidestep step therapy
Posted at 5:37 AM
A bill passed unanimously by the state Legislature provides patients and
doctors with an expedited process for getting exceptions to step therapy —
a common practice, also known as “fail first.”
By Amy Neff Roth <firstname.lastname@example.org>
Verona resident Kathleen Arntsen had a lot more than 2017 to celebrate on
New Year’s Eve.
The governor signed a bill that evening for which she and many health
advocates across the state had fought hard for the last six years. The
bill, passed unanimously by the state Legislature and backed by dozens of
health advocacy groups, provides patients and doctors with an expedited
process for getting exceptions to step therapy.
Step therapy is a common practice, also known as “fail first”, through
which insurers require patients with certain conditions – such as
heartburn, high cholesterol and rheumatoid arthritis – to start treatment
on a widely effective, relatively inexpensive medication. If that treatment
doesn’t work, patients move to the next step. Once patients have moved
through all the steps – and the number varies depending on the insurer and
patient’s condition – the patient can go on another medication.
“Forcing patients to fail treatment based on cost consideration, not
clinical consideration, can be dangerous and harmful and it is ethically
inappropriate,” said Arntsen, president/CEO of the Lupus and Allied
Diseases Association, who herself has multiple autoimmune diseases.
If a health care provider believes that the medication called for by step
therapy is not the best choice for the patient, the new law provides an
appeals process that must bring a decision within 72 hours, or 24 hours in
an emergency. Patients and providers had complained that the previous
appeals process was too slow, delaying care unwisely.
“If they’re easing up restrictions on step therapy, that’s phenomenal,”
said Steve Wood, director for insurance programs for ACR Health. He said
he’s particularly seen patients have problems with step therapy for
insulin, asthma inhalers and mental health medication.
“Health plans utilize step therapy protocols in a limited number of
high-cost drug classes, in which there is an equally effective and more
affordable alternative,” said Deborah Fasser, spokeswoman for the New York
State Conference of Blue Cross and Blue Shield Plans. “This practice also
protects consumers from having to pay higher premiums based on unnecessary
high cost drugs that are aggressively marketed by drug manufacturers.”
Insurers did not back the bill, arguing that an appeals process already
existed and that it would drive up health care costs.
“Our health plans continually strive to provide consumers with quality,
affordable health coverage,” Fasser said. “One of the biggest threats to
achieving this goal is the rising cost of prescription medications.
Prescription drug costs are increasing by double digits and growing faster
than spending on any other health care service.”
But in some cases, doctors know that a particular drug is not the best
option for a patient, but the old appeals process slowed the already often
slow process of finding the right drug combination for a patient, argued
Glenn Liebman, CEO of the Mental Health Association in New York State.
“With mental health, we know what happens,” he said. “Somebody gets on a
medication through step therapy that might have been not appropriate for
them. And …; I think more with mental health medications, it takes a
while to titrate the person off that medication (if it doesn’t work). You
have that weaning process,” he said.
Step therapy is fine for the average patient, but not for those with more
complex conditions or unusual situations who don’t do best with a
“one-size-fits-all” approach, Arntsen said. Delaying physician-recommended
care can drive up costs if patients get sicker, she said.
Arntsen went through step therapy once for eye drops, she said.
“In the long run, it was costlier for them to make me fail than for them to
just give me the appropriate treatment up front,” she said.
She said language in the bill limits the circumstances in which appeals
will succeed. Insurers called the language too vague, though.
They also called the timing problematic.
“Plans have already submitted, and the Department of Financial Services has
approved, product filings, contracts and rates for 2017 policies – for the
New York State of Health (NYSOH, the state’s health insurance exchange) and
off-exchange coverage,” read a statement put out by the New York Health
Plan Association. “And there is no process to add to or otherwise modify
these policies, nor adjust premiums to reflect the new costs of the bill.