By TINA REED
The Capital of Annapolis
ANNAPOLIS, Md. (AP) — It’s taken years for Dr. Ronald Sroka, a Crofton primary care physician, to hone his skill at prescribing what he considers the right medications.
But while he trusts his formula for prescribing meds, he also knows his patients’ insurance companies may not agree. And in what’s called “step therapy,” those insurers can also refuse to pay for drugs unless a patient has tried and failed with older, presumably cheaper, therapies first.
“It precludes physicians from being able to individualize care,” Sroka said. “No two patients are the same.”
He is among doctors supporting state legislation that would limit the step therapy policies in Maryland.
The legislation would cap the time an insurer can require a patient to go through the step therapy process at 30 days. It would also allow physicians to override protocols by insurance companies if the decision is based on clinical evidence and in the interest of the patient.
Similar legislation has been proposed in California and New York. The legislation will be discussed in a state Senate work session Friday.
But when managing expanding U.S. health care costs is a national priority, tackling cost containment measures, such as step therapy or fail-first policies, is anything but simple.
“It’s a common practice,” said Dr. Linda Bergthold, a health policy consultant and former member in Hillary Clinton’s Health Care Reform Task Force.
Insurers say step therapy helps manage costs by identifying drug categories that give doctors safe and effective treatment alternatives.
In Maryland, CareFirst BlueCross BlueShield said step therapy was designed to push physicians and patients to use a more evidence-based approach to treatment.
“Step therapy allows for gauging a patient’s response to medications with the best record of efficacy and safety before subjecting the patient to higher-risk drugs that may result in complications such as addiction, cardiac arrhythmia, heart failure or intestinal ulcers,” CareFirst said in a statement.
“This often results in a lower co-pay for the patient,” the insurance company wrote.
In certain contexts, Bergthold said, step therapy makes sense. Studies have shown mixed results regarding the success of back surgery in alleviating back pain, and it makes sense to first encourage less invasive physical therapy, she said.
“Insurers aren’t doing step therapy for random reasons. They are doing so with scientific evidence to back it up, I assure you, or they’d get sued.”
Bergthold said legislation to limit step therapy seems premature given questions about how health care reform will affect patient coverage.
Maryland physicians say the practice undermines medical expertise while creating burdens on doctors’ time and putting patients at risk. The Maryland State Medical Society, or MedChi, is lobbying for the limits to step therapy.
“The insurance company is essentially practicing medicine here,” said Dr. Gary Pushkin, an orthopedic surgeon in Baltimore and a MedChi member.
Step therapy places a particular burden on patients in Dr. Samip Patel’s practice, where he often sees patients who suffer from seizures. The Anne Arundel Medical Center medical director of Epilepsy and Clinical Neurophysiology said the more seizure patients switch medications, the more they risk seizures.
Many of the older medications he might prescribe require a patient to come in for regular blood work because side effects can interfere with the liver, he said.
He said newer medications don’t require as much blood work and have more convenient dosing schedules, but cost comes into play.
“The insurance companies may approve it, but it really becomes prohibitively expensive for the patient,” he said.
One of Pushkin’s patients had extraordinary results when a particular type of medication for lubricating joints lasted three years rather than the typical six months. But she was denied coverage for the injectable medication when she returned for more unless she received tests and tried other meds, Pushkin said.
“It’s about saving the insurance company money,” Pushkin said. “The crazy thing about it is it often leads to more tests, more therapies, which end up costing more.”
(Copyright 2013 by The Associated Press. All Rights Reserved.)