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.