An increasing number of insurers are using step therapy protocols, which mandate that a patient try and fail 1 or more formulary-covered medications before providing coverage for non-formulary or non-preferred medications that were originally prescribed by the patient’s physician.
Numerous patient advocacy and healthcare provider community organizations have expressed serious concern about the impact of these protocols, and are supporting the passing of the Restoring the Patient’s Voice Act (H.R. 2077). This bipartisan legislation would give healthcare providers the final say in how they treat their patients.1 More specifically, it would require group health plans to implement a clear process for patients and providers to request exceptions to step therapy, outline the circumstances warranting such an exception (including situations in which the lower-cost treatment is known or expected to be ineffective or harmful to the patient), and require health plans to establish a reasonable and clear time frame for granting exceptions.
More than 20 organizations involved in the care of patients with rheumatic diseases, including the Alliance for Patient Access, the American College of Rheumatology, the Arthritis Foundation, the Coalition of State Rheumatology Organizations, CreakyJoints, the Crohn’s & Colitis Foundation, Global Healthy Living Foundation, the Lupus and Allied Diseases Association, and the National Psoriasis Foundation joined forces to send a letter to Congress in which they expressed their support for the legislation.
“As advocates for the patient and healthcare provider communities across the nation, and the millions of individuals we collectively represent, we offer you our strong support for H.R. 2077. We believe this common sense, bipartisan solution will garner a positive impact on many individuals who struggle needlessly to manage their disease state and overall health,” the letter, dated May 24, 2017, said to Congressman Brad Wenstrup, DPM (R-OH), and Congressman Raul Ruiz, MD (D-CA), the authors of the legislation.
The letter also praised the congressmen’s ongoing work to increase patients’ access to important medical treatment.
“Your bill recognizes that before a health plan can deny outright or delay a patient’s ability to access a medically-necessary treatment—specifically with prescribed medications—that federal health plans and private employers’ health plans should consider the patient’s medical history, respect the health care provider’s professional judgment, and take into account the provider’s expertise in partnership with their own patient.”2
The American College of Rheumatology and the Arthritis Foundation also discussed the negative impacts of step therapy on patients with rheumatic diseases in a recent article, stating, “No patient should be forced to endure ineffective treatments just to satisfy an insurer’s unnecessary step therapy process. Rather, the patient’s relationship with his or her physician—and that physician’s understanding of the patient’s disease and unique medical history—must remain paramount in the clinical decision-making process. That’s why it’s important that Congress stand up for the millions of Americans living with rheumatic diseases and other chronic conditions by supporting this common-sense legislation.”3
On its website, the American Gastroenterological Association (AGA) stated, “AGA is concerned that a growing number of patients with inflammatory bowel diseases who are often treated with biologics are being subjected to step therapy protocols that can have adverse health effects on patients who fail or do not respond positively to the medication that the insurer is forcing them to try.”4
Acknowledging the significant impact of reforming step therapy, Congressmen Brad Wenstrup and Raul Ruiz said, “In the days ahead, we look forward to working with our colleagues on both sides of the aisle to streamline the process for patients who require more individualized care. While this legislation is only targeted at one problem in our healthcare system, it represents an important step towards restoring the doctor-patient relationship, which serves as the cornerstone of quality health care.”5
- Congress.gov. H.R.2077 - Restoring the Patient’s Voice Act of 2017. April 6, 2017. www.congress.gov/bill/115th-congress/house-bill/2077. Accessed December 5, 2017.
- United States House of Representatives. Letter to Congressmen Brad Wenstrup, DPM, and Congressmen Raul Ruiz, MD, on The Restoring the Patient’s Voice Act of 2017. May 24, 2017. https://wenstrup.house.gov/uploadedfiles/hr2077_letter_of_support.pdf. Accessed December 5, 2017.
- Lakhanpal S, Palmer AM. Instead of ‘fail first,’ put patients first. The Hill. October 20, 2017. http://thehill.com/blogs/congress-blog/healthcare/356313-instead-of-fail-first-put-patients-first. Accessed December 5, 2017.
- American Gastroenterological Association. AGA and Step Therapy Coalition advocate for patient protections. November 30, 2017. www.gastro.org/news_items/aga-and-step-therapy-coalition-advocate-patient-protections. Accessed December 5, 2017.
- Wenstrup B, Ruiz R. A step towards better health care. The Hill. October 18, 2017. http://thehill.com/blogs/congress-blog/healthcare/356083-a-step-towards-better-health-care. Accessed December 5, 2017.