People over profits - abolish step therapy

People with chronic illnesses and rare diseases are well familiar with "step therapy", which is also known as "fail first" policies. Step therapy is a policy US health insurance companies implemented to lower their cost. The aim of step therapy is to replace costly medications with cheaper ones. The problem lies in the fact that many of the medications that patients need are cutting edge, very expensive drugs. With step therapy, the insurance company only approves old and cheaper drugs when a patient is prescribed an expensive medication. The insurance companies will automatically refuse doctor's authorization requests for better medication until it is proven that the patient absolutely cannot tolerate the cheaper drug. And the bar for "not being able to tolerate" a drug is very high. 

In my case with my autoimmune illness, I was prescribed a biologic medication. My insurance company would not approve it and instead said I needed to try an older, much cheaper drug called methotrexate. Methotrexate is a chemotherapy drug that has very harsh side effects. But it is cheap to produce. My rheumatologist applied for authorization for my biologic injections several times, but kept getting denied.

I suffered tremendously from G.I. side effects from methotrexate for four months. It was not until I had been to the ER three times and was hospitalized one time with gastrointestinal problems that my gastroenterologist wrote my rheumatologist a letter stating that if I was to continue taking methotrexate, he believed I would perforate my intestines. Only then, armed with this letter, did my rheumatologist's subsequent authorization request get approved. While I do have side effects with my biologic (ENBREL) injections, they are far more manageable. I have not had to go to the ER once these past seven months. Patients who suffer, but not as dramatically as I did, will often never be approved for the medication their doctors want for them. They will continue to suffer with the cheaper drug. We must take the profits over people approach out of our healthcare system! Health insurance companies need to let doctors do their jobs without cost curbing policies getting in the way.

Patient advocacy groups have unsuccessfully tried to get limits on step therapy many times. The PAN Foundation, a US charitable group that provides financial assistance for patients who cannot afford their medication, is currently promoting the Safe Step Act (HR 2630/S.652.) to help patients access the best treatment for them, safely and efficiently. Please take a moment to ask your representatives to support this important legislation. Every email counts. Here is their link to a quick and easy action that voices your opinion that patients should come first over profits.

This post deals with the dangers of step therapy to patients in accessing their best medication. But there are other roadblocks to patients getting the medication they need. Once a patient is able to get the prescribed cutting edge drugs, then the issue becomes affordability. Even when insurance is covering part of the costs, the patient will often not be able to afford their co-pay. 

This is because pharmaceutical companies hold patents on their drugs that allow them to set their prices unchecked. These patents block any production of these drugs in a generic form. My Enbrel weekly injections cost me a co-pay over $2500 per month. I cannot afford this. Lucky for me, I have the technological means and skills to seek and apply for online patient assistance programs and I was awarded a grant from the pharmaceutical company that makes Enbrel. I spent four months trying to get patient assistance, all the while suffering from my illness without any medication. Mine is a yearly grant that I will need to keep  applying for. I am keeping my fingers crossed. 

So, we also need to take the profits over people approach out of the pharmaceutical industries. That is a formidable task and another blog post. But do not get discouraged. Just do your part today. All roads start with a single step.