It's called "step therapy" and the practice, which is meant to cut the costs of prescription drugs, is causing conflicts between physicians and insurers, according to a report by KRCU radio in Missouri.
Under step therapy, many insurance companies require patients to use a less expensive alternative for a medication, which the insurer chooses--not the patient's doctor.
In an interview, Victoria Damba, M.D., a family physician with Midwest Health Group in Missouri, told the radio station why step therapy is causing problems throughout the country. As a physician she writes a prescription for a medication she feels is appropriate for a patient, Damba said. That prescription is sent to the pharmacy, which then checks with a patient's insurance company to see if the insurer will cover the medication. Sometimes the insurer says patients must use a different medication if they want the cost covered, or pay out-of-pocket for the drug their physicians ordered.
"It's a huge issue," Damba says. For instance, a pharmaceutical representative told her that come July 1, the drug he is promoting will become the preferred medication for a particular insurance company. Come that date, she will need to change medications for patients covered by that insurer despite the fact their symptoms are under control with their original drug.
It's upsetting for both patients and doctors. "It forces the patient to have to change medicine," she said, even though the drug may not be better to treat their condition, because they cannot afford to pay for the drug out-of-pocket. Currently, there is legislation under consideration in Missouri that would in part shield patients from this practice, she said.
Even though drug spending increased in 2015, a recent report offered evidence that health insurers' efforts to push back against climbing costs are having an effect.
To learn more:
- read the interview