A Step Too Far: Congress Must Act On Insurance Company Tactics That Delay Critical Care For Patients

What harm can come from trying a cheaper medication first? For one woman in Tennessee, it cost her her vision. An eye condition called age-related macular degeneration already blinded her in one eye and was beginning to affect vision in her other eye when her ophthalmologist prescribed a specific medication to give her the best chance to keep her sight. But her insurance company refused to approve it, instead demanding she undergo an alternative treatment first, even though her ophthalmologist knew it would be less effective. The result was tragic. She’s now blind in both eyes.

Step therapy, also known as “fail first,” occurs when a patient is required to try and fail on a lower cost drug before they are allowed to access the drug originally prescribed by their physician. Not only does this practice harm patients by delaying access to the most effective treatments but it increases frustration and costs for patients as they seek treatment. For physicians, it often arbitrarily overrules our years of medical education, training, and relationship-building with patients.

No patient should have to battle with their insurer for the doctor-prescribed care they need. Fortunately, there is hope for patients and physicians as Congress considers legislation to rein in the dangerous insurance company practice called step therapy. If passed, the bipartisan Safe Step Act of 2023 would require employer-sponsored health plans to establish a clear process for requesting an exemption to step therapy.

Step therapy goes affects all fields of medicine, from oncology to rheumatology, and psychiatry.

Step therapy can put patients through several painful months of delay, exposing them to life-altering, long-term consequences, as they suffer severe side effects and irreversible disease progression. Imagine losing your sight – your independence – because of delays caused by your insurer and decisions made by administrators who never went to medical school.

That is not how healthcare should work. Physicians work to develop close relationships with patients and invest the time to thoroughly understand medical histories. Insurers don’t. That’s why treatment decisions should be made by doctors and their patients. Allowing insurers to dictate which therapies patients can and cannot access is akin to practicing medicine without a license.

In addition, step therapy and other health insurer barriers create new administrative burdens for physicians and practices. Just navigating insurance companies’ labyrinthine approval and billing processes forces many practices to hire additional administrative staff just to handle the paperwork. At a time of historic demand for care, it is an expensive diversion of resources that would be better spent on patients instead of paperwork.

Finally, health insurers claim that step therapy is necessary to ensure cost-effectiveness in the healthcare system. However, these fail-first policies compound the cost of care by increasing the chance that a patient will require additional healthcare services as their condition worsens. At the same time, it increases the administrative burden on physician practices, as they deal with all the red tape.

Now is the time for Congress to address this issue and pass the Safe Step Act of 2023 as part of any commonsense healthcare legislative package. This bipartisan legislation will help create a more transparent process that allows patients and physicians to seek exceptions to step therapy protocol. Although it only applies to employer-sponsored health plans, the bill represents an important step towards reining in this troubling practice. This is a top priority for patients and should be a top priority for policymakers seeking to improve our health care system. We urge lawmakers to pass step therapy reform that reins in harmful policies.

If you’re a patient who has experienced step therapy barriers, reach out to your lawmakers now and let them know you can’t afford to wait any longer.

Photo: MikeyLPT, Getty Images

Daniel J. Briceland, MD, is an ophthalmologist in private group practice with his wife Susan Briceland, MD, a gynecologist in Sun City West, Arizona. He also serves as a clinical assistant professor at the University of Arizona College of Medicine.

Dr. Briceland is an active member of the ophthalmology community, including serving as the current president of the American Academy of Ophthalmology, the world’s largest association of eye physicians and surgeons. He held previous leadership positions at the Ophthalmic Mutual Insurance Company and the Arizona Medical Association. He received his medical degree from the University of Rochester.

A fierce advocate and physician leader, Dr. Briceland has a long history of involvement in organized medicine. He believes physicians have a responsibility to advocate for their patients since they are uniquely positioned to understand the complex nature of our healthcare system and discrepancies in the care provided.