Millions of Californians who have health insurance still may not be able to access the crucial medications and treatments they need.
In an effort to contain costs, some California health insurers have instituted policies to encourage the use of cheaper medications. One such policy is called “step therapy,” which requires that some patients try a cheaper, often older and inferior medication before the insurer will cover the medication originally prescribed by a physician.
When step therapy policies are based on well-developed scientific standards and administered in a flexible manner that takes into account the individual needs of patients, they can play an important role in controlling healthcare costs.
In some cases, however, requiring a patient to follow a step therapy protocol may have negative and even dangerous consequences for the patient. For some patients, the insurer-preferred prescription drug may not provide any benefit, while other patients may suffer irreversible deterioration of their condition.
It is imperative that step therapy protocols preserve the right of physicians to have a say in treatment decisions.
Thankfully, the California Legislature has an opportunity to put patients first by making important, common-sense reforms to step therapy.
Assembly Bill 374, which passed out of the Assembly (63-14) and is heading to the Senate, would allow a doctor to request an override of an insurance company’s step therapy protocol if the doctor believes the medication that the insurance company wants the patient to use as a substitute isn’t in the best interest of the patient. In short, the bill restores the balance between the physician’s knowledge of the patient and the cost-saving controls of health plans and insurers.
As the entire healthcare system, including insurance companies, faces rising medical costs, we must ensure that patient outcomes remain at the forefront.
When patients are unable to receive the proper medicine, this could result in costlier medical care in the future. In addition, patients tend to schedule frequent follow-up visits with their physicians when the step therapy is not helping them. The end result is not just unnecessary financial costs but also needless pain and suffering and potential disability.
Modern medicine has brought breakthrough therapies for conditions that once were debilitating. For the 5 million Californians who contend with arthritis — a condition I treat almost every day as a rheumatologist — new medications can mean the difference between being active and going on disability. The same is true for countless patients across our state living with mental illness or battling other chronic conditions.
But medical breakthroughs will only benefit California patients if they are able to gain access to them.
As a doctor, I see patients fighting to overcome their medical conditions. It’s time lawmakers in Sacramento supported sensible reforms to step therapy — reforms that would keep the system in place but ensure that an override can be requested when clinical judgment says doing so is in the best interest of the patient.
WESLEY MIZUTANI is a rheumatologist in Huntington Beach. He is chairman of the Arthritis Foundation’s California Advocacy Council.