Health Insurance

The problem with step therapy

Step therapy is good in theory, but often not in practice.  In step therapy, patients are required to try one drug first–typically a low cost and/or high-value treatment–before moving on to more expensive alternatives.  In theory, this is a great idea.  The first drug patients should try should be the highest value one.

In practice, however, step therapy does not always work out as planned. Stat describes some of these issues. Broadly, step therapy doesn’t work due to asymetric information.  Typically there is private information that patients and physicians have that insurers do not have.  For instance, how does one define whether a patient “failed” a therapy.  Clinically this may be easy to do in many cases, but for payers this information is difficult to observe.

The practical issues described above highlight some shortcomings when step therapy is administered well.  Oftentimes, however, it is not.

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.”

More broadly, Blankenstein summarizes the problem with step therapy as follows.

“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…It’s taken away clinical judgment. It’s managing by algorithms.”



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