A cost cutting practice for prescription drugs known as “step therapy,” is driving a wedge between insurance companies and doctors. With the rising cost of prescription drugs, many insurance companies are requiring patients to use a cheaper alternative of the insurer's choice to cover the cost. KRCU’s Marissanne Lewis-Thompson spoke with Midwest Health Group physician, Dr. Victoria Damba about why step therapy is causing problems for some Missourians.
Lewis-Thompson: So, let's break down what exactly step therapy is.
Damba: As a physician I write a prescription for a medication for a patient that I feel is appropriate for that particular patient for whatever I'm treating. And I send that prescription to their pharmacy. And then their pharmacy checks with their insurance company to see if they're going to pay for it. And sometimes they don't. And sometimes they give us the option [to] instead of just not prescribing a medication to go through a process where we can either get that medication approved, or we have to use a different medication that the insurance company says that we can use.
Lewis-Thompson: How does this conversation come up between insurers and patients?
Damba: Probably whenever they go to try to pick up their medication and the pharmacist will say 'well your insurance company isn't playing for this. So that'll be $250 bucks.' Or whatever. You know some exorbitant amount of money that of course the patient isn't going to pay. Now sometimes though [the] patient has been on a medication for a while and this is the bill that we're looking at. They've been on this medication for awhile and their insurance company negotiates medication prices with their pharmacy and says 'well we're only going to use this medicine.' So they will send a letter to the patient and to me to let us know that we are no longer going to pay for this. So you need to talk to your doctor about options.
Lewis-Thompson: How big of an issue is this in Missouri? What about rural communities in Missouri?
Damba: It's a huge issue. And I wouldn't say it's just rural. I mean it's everywhere. I can give you a prime example yesterday I was talking to a pharmaceutical representative. And so, he's telling me about his medication that he is representing and tells me that come July 1 that this medication is going to be the preferred medication in this class for x,y,z insurance. And I don't even remember the insurance [company], because it just made me upset to think about. But come July 1, people that I have on another medication and their symptoms are doing fine. Their disease process is under control. I will have to change their medicine to his medicine, because now it's preferred. And he even says, he admits that their medicine is not necessarily better, but it's about market share.
Lewis-Thompson: So why is the practice of step therapy problematic for both doctors and patients?
Damba: The problem that we're trying to focus on to improve is patients on medications that they have been stable and therapeutic. In other words, it's helping their disease symptoms for a long time. And then all of a sudden the insurance company would say 'well we're going to start using this medicine, because we've negotiated a better deal with this pharmacy.' And so, it forces the patient to have to change medicine. Well the problem is that you know they've been on that medicine, and they can't afford to pay for that medicine out of pocket. So, they can go through a period of time when they don't have the medicine. And if they don't have the medicine let's say it's a painful disease like rheumatoid arthritis you know then their arthritis symptoms start flaring up. And [they] can be incapacitated. When they were on the medicine they were doing great. They were functional. They weren't in pain all the time. And so it can cause a lot of pain. Obviously, a lot of anxiety. Financial stress if they try to pay for the medicine. So many times from these medicines there's no way you can afford to pay for them month after month after month.
Lewis-Thompson: Does this practice prevent individuals from getting access to quality medication?
Damba: I think at times. Yes, I do.
Currently, a Missouri bill has worked its way through the House and the Senate Veterans and Health Committee. The bill would in part shield patients from the practice of step therapy.
