To Counter Sales Reps, Insurers Push Step Therapy
9 CommentsBy Ed Silverman // May 5th, 2008 // 8:02 am
The battle to lower prescription drug costs is causing still more friction between doctors and insurers. Take the case of Lloyd Negoescu, who took Lopressor to stabilize his blood pressure, until his Medicare Part D plan changed, and his new insurer, RxAmerica, stopped paying for the brand-name med.
His doctor wrote letters to appeal, to no avail. “They wanted me to try generics first. My blood pressure went up astronomically on the new drugs,” the 57-year-old disabled man tells The Star-Ledger of New Jersey. Negoescu is an example of what’s known as step therapy - requiring patients to try and fail with lower-cost meds before insurers will pay for more expensive, brand-name, drugs.
To insurers, the practice directs patients away from costly meds and toward equally effective, established drugs, including generics. They say the effort is needed to curtail soaring drug bills and offset advertising that pushes expensive brand name treatments. In New Jersey, state guidelines prevent step therapy, but docs say insurers are finding ways around the guidelines, the paper writes.
John Ciccone, a member of a physicians group and a cardiologist, says one patient stabilized on the blood pressure medicine Atacand, but when insurance coverage switched to Aetna, he received a letter saying Aetna wouldn’t pay for Atacand unless the patient failed four other blood pressure drugs. Ciccone made the change and the patient’s pressure soared.
Because Medicare Part D plans are regulated by the federal government rather than the state, insurers can use step therapy to curtail costs. RxAmerica wouldn’t comment on Negoescu’s case, but told the paper most patients are satisfied and able to save money with the practice. The insurer added that docs can send prior authorizations to get brand names if substitute drugs do not work.
Ira Klein, medical director for Aetna’s northeast region, says the insurer would have approved the drug for Ciccone’s patient. “If a certain drug already is maintaining a patient and the patient is stable, we would approve that drug,” he tells the paper. “The doctor has to give us a call.”
But Ciccone says he can’t appeal every denial. “There is no such thing as a simple phone call to an insurance company,” he tells the Ledger. “Every call takes 30 minutes to 60 minutes…They are parsing words. No matter what you call it, they are meddling with medicines that work for patients.”
Docs say insurers are challenging their prescribing in many areas, such as drugs for allergies and acid reflux disease. “Many of the companies want to see that you’ve tried an over-the-counter drug first,” Susan Volpicella-Levy, president of the New Jersey Association of Osteopathic Physicians, tells the paper. “I want to be the one making decisions for my patients, not the insurance company.”
A spokesman for the state Banking and Insurance Department says that some insurers may skirt the rules by charging high co-pays for expensive drugs, or by requiring difficult-to-obtain pre-certification.
“If they say, ‘We have to pre-certify you for drug A, but what you really want is drug B,’ then that comes dangerously close to (step therapy). We would investigate any abuses,” Rogan tells the paper, and adds that state law allows doctors to override insurers if medically necessary.
Aetna’s Klein insists the insurer doesn’t practice step therapy, but instead uses “softer steering processes that use pre-certification to allow for the selection of the least costly and most effective drug.” He also said the practice counters the efforts by sales reps who visit doctor offices pushing the latest and most expensive drugs.
Pharmalot, by the way, is owned by The Star-Ledger of New Jersey
Beth
Step care therapy is from the 1970s, the name was a tad different, pyramid therapy. We now know much more concerning hypertension than we did then and have adapted our therapy accordingly. JNC7 recognizes the latter. Should Bob in the accounting department at RxAmerica be able to dictate what the patient needs to lower their BP?
Dan
Step therapy is kind of like saying we will hold off treatment of your cellulitis until gangrene sets in, and then we will initiate the right treatment.
Nathan
Talk about practicing medicine without a license….
Skeptic
The limitation of step therapy is that the protocols are derived from population-based drug evaluations, some of which are well-designed while others are not. Applying it rigidly to the patient-level is not in the patient’s best interests, especially when the patient fails on the initial step.
Unfortunately, the admistrative process for moving patients through the steps are cumbersome and tie up scare physician time. Step-therapy is a good concept but the breakdown occurs when the process becomes more important than patient considerations.
Justice in Michigan
Looks like a lot of agreement on this one. To me, it’s one thing to _start_ a pt. on a generic. But to switch pts already doing well is something else.
Yes, many will be fine. But how to balance those and overall cost-savings against those who do not do fine?
Also relevant to determine what sort of incentives (besides lower cost of generic itself) may be being offered to insurers to induce switching.
Bob Freeman
Justice, as much as people talk about looking at the total impact on resource utilization and costs the reality is that budgets are siloed. So, if the drug budget is controlled there’s no assessment on the impact on other line items such as extra physician visits, ER utiliztion,etc. It’s been that way for decades and in spite of the rhetoric, I don’t see it changing.
Managed care has put so much reimbursement pressure on community pharmacies (very low professional fees) that about the only place left to cut is in ingredient costs, which are about 70-75% of the total price per prescription. The other place to put pressure is, of course, on consumers through formulary tier systems.
Kris Selvig
The assertion by RXAmerica that “docs can send prior authorizations to get brand names if substitute drugs do not work” is a crock. We’ve tried several times to get them to approve two medications and they have refused all attempts. After being stabilized for three years my 86 year old mother (heart patient) is now having to pay out of pocket full price for the drugs she NEEDS.
Susan
Until Dilantin was approved as a brand name drug with generic qualities, I would have agreed that these insurers were wrong.
HorusCat
You are all right. The theory is good, but the practice fails miserably, because insurers use the PA and step process to beat the docs and patients into submission.
Often the step therapy involves meds with undesirable side effects (tricyclics for pain) that aren’t even indicated for the condition they are to treat. By the time the patient cycles through 2-4 meds to get to the one that works, the patient is exhausted and angry, the physician has spent hours of his/her time and his/her staff’s time, and the actual costs of care of much higher than just approving the right drug in the first place.
Furthermore, when a patient switches plans, even if they HAVE failed the prior drugs, the new payer requires the patient fail them all AGAIN.
Finally, a double standard exists–payers will often refuse to approve non-approved brand name drugs because they aren’t indicated, yet REQUIRE off-label use of generics (the fibromyalgia protocols in place are a perfect example).
Physicians can usually get what they want by requiring a “doctor-to-doctor” consult–but this is very time-consuming.
As was noted earlier, costs are “siloed,” so what is “saved” in drug costs may indeed increase other costs, but this will not be registered. With drugs constituting the minority of costs to the system, it is penny-wise but pound-foolish to focus all our efforts on reducing medication costs. We would save far more money to the system by revamping end-of-life care, implementing true triage in the ERs, and requiring patients to pay more for their care so that they have incentive to manage their health better.