Step Therapy: Health Insurance Companies Control Patient Care

Step therapy, also known as “fail-first” therapy, is a shockingly common strategy used by health insurance companies to cut their costs. This method forces patients to experiment with cheaper drugs and treatments before the health insurance company finally approves more expensive options, even if their doctor determines early on that the pricier treatment is the best path forward. 

This approach might make sense for the health insurance companies’ bottom line, but it’s a massive insult to patients. The experimentation on low-end treatments causes delays in receiving vital care, and in some cases even threatens their life. 

‘Step Therapy’ vs Patient’s Dignity

Health insurance companies use step therapy protocols for a number of health conditions which significantly affect the quality of patient care. 

Cancer patients, for example, often can’t afford to wait. Step therapy protocols require patients to try old or less effective chemotherapy treatments before they can receive newer more targeted immunotherapies like Keytruda or Opdivo. 

These new immunotherapies are an innovative breakthrough in medicine that save lives for specific types of advanced or aggressive cancer. Additionally, the treatment works differently by firing up and training the immune system to actively destroy cancer cells in the body. A very different path from traditional chemotherapy, which kills cancer cells while also destroying the patient’s immune system.

Patients with multiple sclerosis (MS), a debilitating nerve disorder, also commonly must deal with step therapy protocols. Although there are cutting-edge treatments available on the market like Ocrevus or Lemtrada, which have shown to slow down the rate at which MS progresses while increasing the quality of life for MS patients, health insurance companies are known to have these patients try older and less potent options like Avonex or Copaxone. 

If these patients “fail” or their condition worsens on the older options, then health insurance companies might consider covering the newer more expensive medications. These delays, if coverage is granted at all, can cause lasting harm and exacerbate preventable problems.

Step therapy protocols are even used for obesity treatment. Now that innovative GLP-1 weight loss medications have entered the market like Ozempic and Wegovy, it seems as though many patients are eager to get their hands on them to help control their weight and boost overall health. 

Some health insurance companies require patients to try options like diet, exercise, or older medications like Phentermine or Orlistat before approving newer treatments. These older treatments may not work well for everyone. Forcing patients to stick with outdated, less effective options just to save insurance companies money is unfair and needs to change. 

It is an affront to the dignity of human beings suffering through an illness to not be approved for the best possible treatment as quickly as possible. 

A Better Way to Balance Healthcare Costs

The step therapy model we have within our healthcare system now puts money above patient care and choice, but there are better ways forward to balance healthcare costs while ensuring patients get the treatment they need when they need it.

A simple solution would be to allow doctors to override step therapy when they believe a newer or more effective treatment is needed. This would give physicians the power to choose the best care without unnecessary delays, leading to better patient outcomes. Quick access to the right treatments can help prevent further health complications and reduce long-term healthcare costs. Another option that should be explored is patient-centered plans that prioritize transparency. Consumers should have more options when choosing their health insurance, and more transparency from the health insurance companies regarding what their plans will and will not cover, how they determine step therapy protocols, transparent pricing, and all other pertinent information that will help consumers decide which health insurance company and plan is right for them.

Health Insurance Coverage Denials: A Threat to Consumer Choice

Health insurance companies are facing justified criticism for denying claims more often and becoming increasingly unlikely to cover vital, sometimes life-saving, treatments. These denials go beyond complex medical procedures or expensive experimental drugs – they are now affecting even basic preventative care, which consumers expect as baseline components of their health insurance plans. Unfortunately, this reveals another layer of a growing trend wherein insurance companies put profits above patients. To help patients stop health issues before they start, we need to make changes that hold health insurance companies accountable while still allowing patients the choices in healthcare they deserve. 

Need for Data & Transparency on Coverage Denials

Throughout the country, health insurance companies are denying more and more claims for necessary medical care. In 2022, an estimated 15 percent of all claims submitted to private payers faced denial, including treatments and services that had received pre-authorization. 

This number could be much higher, as current reporting requirements for health insurance companies don’t require full disclosure of their denials. The Affordable Care Act granted federal regulators the ability to collect information from health insurance companies on their coverage denials, however only a fraction of the information has been collected thus far. What little information and data was released has been deemed by experts as so crude and inconsistent that it is essentially meaningless.

This lack of transparency leaves patients blindly entering into health insurance plan contracts without knowing fully what they will and will not cover – and if they face a coverage denial, then the choice is often to let their health deteriorate or pay the exorbitant out-of-pocket costs. 

Real Life Consequences of Coverage Denials

When you acquire health insurance, the hope is that you won’t need to use it, but it’s there to help in case you do. Unfortunately, even while paying all of your premiums and deductibles, a claim for coverage can still be denied.

One egregious example of coverage denial is what was experienced by Sayeh Peterson, who never smoked cigarettes and still learned that she had stage 4 lung cancer at age 57. Her doctors suggested genetic testing to help investigate the cause. The genetic tests showed that a rare genetic mutation had caused her illness, which then helped her medical team to create an effective treatment plan to aggressively attack the cancer. While preventative tools like genetic testing are required by law to be covered by health insurance companies in her state, her health insurance company had denied the coverage, leaving Sayeh with over $12,000 in medical bills to pay on her own. 

Another example is that of U.S. Customs & Border Protection (CBP) agents in Arizona being denied coverage by Blue Cross Blue Shield of Arizona (BCBS) for necessary preventative hearing protection. These agents are plagued with loud noises that can cause significant hearing damage from things like trucks, helicopters, and other gear needed to do their job. To prevent hearing damage and additional healthcare costs from dogging the agents, CBP wants FDA-approved Phantom hearing protection as it guards the user’s hearing while letting you stay alert and in communication with others. Despite BCBS plans covering preventative care, they have refused coverage of Phantom hearing protection to CBP agents, stating it is not a “medical necessity”.

What health insurance companies are failing to understand is that by prioritizing preventative and effective care early on, they save vast sums of money in the long run as morbidities are addressed earlier. This prevents conditions from spiraling out of control to the detriment of both the patient’s and insurance company’s bottom line. 

Time For Reform

The health insurance industry must prioritize patient care over cost-saving measures. 

One easy solution is to require health insurance companies to be more transparent in their coverage decisions. Providers must be open with consumers about denial rates and the standards they use to determine what is and what is not a medical necessity. 

Making this information public will spark competition, push insurers to improve approval processes, and aid consumers in evaluating their coverage options. It’s important we have accountability mechanisms built in where there is easy recourse for patients to rectify a wrongful coverage denial.

Another common sense solution is to encourage preventative care – whether that be genetic testing, hearing protection, or whatever else – so as to alleviate consumer costs in the long term. The faster we can address a medical issue, the less patients’ health and wallets will suffer. 

Insurance Holdups & Hassles

The US healthcare system has a lot of problems, but here’s a big one: health insurance companies demand pre-authorization for many vital treatments and services. They say it is to keep costs down, but in reality, it makes it even more challenging for patients to get the healthcare they need…when they need it. 

Mandatory pre-authorization rules delay treatment, create more paperwork for doctors’ offices, and interfere with doctors and patients making medical decisions together. 

The solution? More transparency and accountability regarding plan coverage and fewer healthcare services requiring a pre-authorization. This way, patients and doctors can make timely individualized healthcare choices without jumping through unnecessary hoops. Having medical issues, whether life threatening or routine, is stressful enough as it is without waiting for insurance providers to green light your treatment. 

Effects on Patient Care

Anyone who has ever used the healthcare system before knows that we’re talking about a space where life literally hangs in the balance. Time is not on everyone’s side. Pre-authorization refusals can cause risky holdups in receiving necessary treatment, dragging on for days or even weeks before consumers get a response from their health insurance provider. In 2023, 22 percent of adults insured under Medicaid experienced pre-authorization problems, along with 11 percent of those insured through Medicare and 15 percent using employer-sponsored coverage. 

You’ve probably heard someone in your life say, “Thankfully, we caught it in time,” when sharing news of an illness. In too many cases, delays result in a patient’s condition getting worse, so much that they need additional pre-authorizations for health care services as a result of the first pre-authorization. Research shows that of the adults who had more than 10 doctor visits in 2023, 31 percent experienced pre-authorization challenges. 

Comparatively, adults who visited the doctor 3 to 10 times had pre-authorization problems at a rate of 20 percent. 

Those who visited just 2 times or less had pre-authorization problems at a rate of 10 percent. 

This demonstrates that those who need more healthcare services are the ones most likely to be denied pre-authorizations, increasing delays and overall harm to their health. 

Patients with serious illnesses are at a major disadvantage with health insurance companies. 

Let’s say you have a rare chronic lung disease that requires special medication and treatment. Your doctor finds a groundbreaking treatment, but the insurance company wants to approve it first. If the insurer labels the treatment ‘experimental’, then you will likely be denied pre-authorization and will find yourself stuck in red-tape limbo while your health continues to deteriorate — even if the doctor recommends action. 

Patients deserve a choice in their healthcare treatments, without health insurance companies getting in the way of decisions made between patients and their doctors. 

Cut Down on Pre-Authorization Rules & Increase Transparency

An easy reform to increase patient choice and enhance care is to reduce the number of medical services that require pre-authorization. Rather than depending on insurance companies to approve treatments beforehand, we would empower doctors to make the best choices with their patients, and reduce outside meddling. 

Additionally, if insurance policies were more transparent, patients could easily compare plans based on which treatments need pre-authorization. This would spark competition among insurers and push them to simplify, or perhaps even get rid of pre-authorization approvals altogether in a bid to attract consumers. 

Pre-authorization denials reveal a broken approach to healthcare that prioritizes cost-cutting over patient health. By reducing services that require pre-authorization and increasing transparency for coverage upfront, we can rip through the needless red tape holding back patients with better healthcare delivery. 

These changes wouldn’t solve all of the pitfalls of the American healthcare insurance system, but it would certainly get us closer to a system that prioritizes patient care above all else.