Today, we live in an era of customization. Increasingly, customers can modify a product’s appearance, features, or content according to their unique needs or desires. Often, even the news we see in our newsfeeds is customized based off our preferences.
Why, then, are so many aspects of the health care industry still one-size-fits-all?
As doctors, we’ve seen firsthand how this can negatively impact patients who require more individualized care. One particular example is a practice known as “step therapy” or “fail first.”
Now, when patients visit their doctors for a prescription, the treatments they are prescribed are typically based on a variety of personal factors. These factors include their health history, underlying symptoms, and their doctor’s long-term understanding of their condition, such as whether they have already tried certain drugs under a different health insurance plan, if they have other medical conditions that might interfere with the drug’s effect, whether certain drug’s side effects will affect the patient’s ability to perform their job, or if the patient would prefer a drug that has a different ingestion method or dosage form. Treatment plans need to be based on the individual’s needs, and their doctors’ medical expertise and first-hand knowledge of their patients’ overall health.
However, far too often, what happens next is the problem. When a patient goes to the pharmacy to fill their prescription, they may be informed that their physician-prescribed medicine will not be covered unless the patient first proves that another medication—one of the insurer’s choosing, not their doctor—will not work for them.
In such a case as this, failure is not only an option, it is the only option before getting appropriate treatment.
Under the current system, patients are left with a limited set of options: either try a medication that is not what their doctor recommended for their condition, or pay out of pocket for the treatment they need. For many people, that’s not a choice at all. They are simply forced to fail on a medication other than what their doctor prescribed.
We recognize that in some cases, implementing step therapy can guide patients towards less costly treatments. Understandably, this protocol is deployed by insurance companies as they strive to control health care costs while maintaining quality care — goals we all can agree on. However, too often, it leaves patients waiting for the care they need. In some cases, their medical condition may be worsening while they are forced to try and fail on multiple medications before finally being able to take the one their physician wanted to prescribe from the beginning. This actually costs more and may result in adverse conditions that require hospitalization.
That’s why we introduced the bipartisan Restoring the Patient’s Voice Act. This commonsense legislation is intended to strengthen and restore the doctor-patient relationship while giving healthcare providers the final say in prescribing the right medication for the patients that they know and care about. It does this by requiring a clearer, faster, more transparent exemption process to be available when a doctor feels step therapy would not be in the best medical interest of the patient.
One reform requires that the exemption process will be easily accessible on the insurer’s website, including clear instructions and contact information for questions.
Additionally, patients will no longer be forced to go through step therapy for a medication they have already failed on, just because they changed insurers.
Limits will be put in place as to how long a patient may be required to wait for a medication when an exemption has been requested. The goal of streamlining the process in this way is to dramatically reduce the amount of time and frustration spent on paperwork for physicians and patients alike, as well as to provide a better, faster process for getting people the individualized care they need.
When patients fail to receive the proper treatment in a timely manner, their conditions worsen. You don’t have to look far to hear story after story from across the country of the harmful impacts that patients have experienced due to delays in access to medication. That’s not even counting the cumulative financial and physical burden — of added visits to the ER, surgeries, additional visits to the doctor— incurred when a person cannot get access to the treatment they need.
We have both received feedback about this issue from the ground up—from our own personal prescribing experiences, our colleagues, and most importantly, our constituents who are being impacted by this practice. In both of our home states, as well as several others around the country, local lawmakers are working to pass similar protections. In California, some step therapy protections were passed in 2015 and in Ohio, legislation is making progress this year in Columbus. But, we need to add protections for people with federally-regulated health plans.
Patients are not one-size-fits-all. Their treatment plans should not be either.
In the days ahead, we look forward to working with our colleagues on both sides of the aisle to streamline the process for patients who require more individualized care. While this legislation is only targeted at one problem in our healthcare system, it represents an important step towards restoring the doctor-patient relationship, which serves as the cornerstone of quality health care.
By Rep. Brad Wenstrup (R-OH) and Rep. Raul Ruiz (D-CA)
Wenstrup represents Ohio’s 2nd District. Ruiz represents California 36th District and is a member of the Energy and Commerce Committee.