I’m doing something this year that I haven’t done before: I’m actually making a new year’s resolution. In 2020, I’m going to write letters to anyone and everyone who can effect change in the healthcare system, asking them to take concrete action to stop insurance companies from overriding doctors’ prescribed treatments by requiring patients to start on less effective treatments first. Insurance companies are allowed to do this under the guise of caring for patients’ safety, their position being that we don’t know that the lesser medications won’t work until patients fail on them.
Such policies are referred to as “step therapy” or “escalation therapy.” What they have in common is that patients start with the cheapest/least effective therapies and then get to step up or escalate only when medications fail them. In MS, this means evidence of disease progression, whether it is marked through relapse or MRI. Because we don’t yet have remyelinating treatments available, each failure represents permanent brain and spinal cord damage. How is that acceptable?
I’ve written about this before. My doctor and I chose Ocrevus as my first therapy because how aggressive the onset of MS was for me, how active it was in causing relapses and damage. My insurance company denied coverage because its policy requires patients to try and fail on two lesser medications first, specifying the injection and pill options for treating the disease. Many of these treatments were created 20-30 years ago, and while they were better than nothing at the time, we’ve had such advancements in MS treatments since then, especially with infusion therapies. Why should we have to fail on medications that we know are less effective before we can access the most effective ones? Or, if we’re going to start with outdated treatments, why not have us begin with leeches?
These policies do not come from a place of looking out for the patients. Insurance companies don’t care about patient wellness; they only care about enforcing policies that support greater profit margins now, even if there will be greater patient costs in the long term. And it doesn’t just affect big decisions about expensive treatments. For example, my insurance company will have to pay thousands of dollars to treat shingles if I contract it, and I’m more likely to because of my weakened immune system, but they refused to pay for the Shingrix vaccine because I wasn’t 50. My appeals were ignored, so I had to pay for it myself to at least have some protection before starting Ocrevus.
Imagine being diagnosed with a form of cancer. There is a treatment available that offers a very good chance of remission, but before you can try it, you need to start with one that is only 50% effective, and when your cancer gets demonstrably worse, you can access the one that is 65% effective, and when your cancer gets demonstrably worse again, you can access the one that is 80% effective, and when your cancer gets even worse, you can finally access the most effective treatment. By that point, you are unlikely to have outcomes as positive as you would have if you’d had access to it early on. This is what people with MS are asked to do. And because there is no cure for MS, treatments can only slow disease progression, so failure is practically guaranteed.
Patients should have the right to receive the most efficacious therapy/medication right away. They should not have to “fail first” on one or more medications, causing irreversible damage to their health. Step therapy policies are barriers to accessing quality healthcare. By allowing insurance companies to get away with ever-increasing step therapy protocols that only look out for their profit margins (which are in the BILLIONS for all major health insurers each year), governments are allowing them to harm their patients. Further, the insurance companies have no incentive to negotiate for lower prices with drug manufacturers for the most effective therapies unless they are legally required to cover those therapies.
I will be suggesting that representatives support a policy that prohibits insurance companies from creating/enforcing step therapy policies for people with chronic health conditions. Specifically, with a physician’s prescription, insurance companies should have to cover FDA-approved treatments for patients immediately; the company may check with the physician to see if step therapy is appropriate but cannot be allowed to override the physician’s prescription.
Or, if step therapy is not something the representative is willing to work against, I will encourage support for policies that limit how such protocols can keep patients from FDA-approved treatments prescribed by their physicians:
- Instead of the current model where doctors and patients must appeal the insurance company’s outdated policies, when step therapy protocols are in place, the burden should be placed on the insurance company to prove that the prescribed treatment will cause harm, be ineffective or that there is a better treatment available.
- If a patient has been stable on an FDA-approved treatment for two years and his/her physician recommends staying on that treatment, then the insurance company must cover it after that, overriding any step therapy protocols they have in place. This means that patients could find another way to pay for treatment themselves at first, but the insurance company cannot keep denying them after two years. It would also help differentiate between chronic health conditions like MS and acute health conditions where step therapy may be appropriate.
- Prohibit insurance companies from denying coverage for FDA-approved treatments if there is no generic equivalent. Equivalency is important because insurance companies currently are allowed to require alternative medications that are not equal to patented ones.
I understand how massive this mountain is. I know that significant changes to step therapy protocols are unlikely, especially given the power of the health insurance industry. But I also know that complacency reinforces policies like this as “just the way things are done,” and I refuse to be complacent about it in the year to come.
Wishing you all a happy, healthy 2020.