Arthritis is just one of many chronic diseases and conditions including cancer, multiple sclerosis and others that can be adversely affected by new step therapy protocols insurers are using in our state.
Step therapy or fail first is a practice that insurers sometimes use to control costs by requiring patients to fail on less expensive prescription medications before receiving the medication that their doctor has prescribed.
In 2013, the state legislature did the right thing in passing legislation that enacts protections from over-reaching step therapy requirements for Medicaid patients. These protections included limiting the number of times a patient can be forced to fail on a drug. They also included limiting the length of step therapy trials to 30 days.
This year, a number of health agencies representing chronic diseases are working to pass a bill, which will guarantee these same protections are afforded to commercially insured patients. In addition, we applaud the addition of an exemption process. The doctor can request an exemption from the sequence of medications required in the step therapy for three reasons. These include: the medication has been ineffective in the past, is likely to be ineffective based on current knowledge, or is likely to cause an adverse reaction or physical harm.
Why is the Arthritis Foundation concerned about step therapy? Arthritis affects a quarter of our state’s adult population or 654,000 residents. It also affects an estimated 3,400 children. It is the leading cause of disability, according to the Centers for Control and Prevention (CDC). Getting the right medication at the right time for patients with inflammatory arthritis can help prevent pain, joint destruction and related disability.
Prescribing for any patient’s treatments is a complex process and is undertaken with many variables in mind. These include the diagnosis, the proximity of the patient to the physician’s office, the patient’s preference for mode of administration, the patient’s ability to be mobile, and the physician’s experience. Doctors know their patients best—and need to have the final say in their care.
It’s time to guarantee Connecticut patients that their physicians—not insurers—are prescribing the most appropriate treatment for their chronic disease.
Susan Nesci is vice president of public policy and advocacy for the Arthritis Foundation.