Doctors complain 'step therapy' undermines patients' health

When he was diagnosed with two autoimmune diseases, Joel Hechler knew he'd be in for a battle. He didn't realize mayb...

Posted: Apr 18, 2018 8:04 PM
Updated: Apr 18, 2018 8:04 PM

When he was diagnosed with two autoimmune diseases, Joel Hechler knew he'd be in for a battle. He didn't realize maybe his toughest one would be with his insurance company.

"I think they put the dollars ahead of a patient's health," Hechler said. "I don't think they fully understand the impact the medicine will have on my long-term health and well-being."

Hechler suffers from Crohn's disease and ulcerative colitis, diseases that attack the lining of his digestive tract. Autoimmune conditions like his can't be cured but, with the right medication, the symptoms can be controlled.

Finding the right medicine can be hard for those suffering from autoimmune diseases. Even if there are scores of drugs on the market, some patients might only respond to one. In Joel's case, his doctor thought he'd have a better chance trying a drug called Remicade.

"I received a letter from my insurance company that denied the Remicade," Hechler recalled, "on the basis that I have to try a different drug before I can get to Remicade."

Joel's insurance company, Premera Blue Cross, wouldn't approve the drug his doctor prescribed because they wanted him to try a cheaper one first.

It's part of a program that health insurers nationwide use called step therapy, requiring that patients try less-costly drugs before "stepping up" to more expensive ones, even if your doctor believes the cheaper drug won't work.

Dr. Larry Adler is president of Huron Gastro in Ypsilanti and says he spends virtually every day battling insurance companies over step therapy drugs.

"They have to fail this medicine first before they get the new drug," Adler said. "That doesn't make any sense."

"You have seen patients get worse because of the delay for step therapy," said Channel 7's Ross Jones.

Adler responded: "Absolutely."

In Joel Hechler's case, it took six weeks of fighting with his insurer to convince them that the cheaper drug wouldn't be effective. As he was waiting, he was getting worse.

"It got to the point where I had to be admitted to the hospital," Hechler said. "I was very, very sick."

Step therapies are used by insurers to try to control skyrocketing prescription medicine costs, says Glen Perry, Director of Pharmacy Contracting and Sales for Blue Cross Blue Shield of Michigan.

"These drugs can cost up to $100,000 per year, these are not cheap medications," Perry said.

"It seems like you're telling patients that, in many cases, your insurer knows what's best for you, rather than your doctor," said Jones.

"We are trying to provide the most cost effective and safe medication use," Perry said, adding that when a doctor and insurer disagree over a drug, they can usually resolve the case within a few days without putting a patient at serious risk.

"A delay of one or two days I don't think is really going to make that much of a difference for the medical outcome of the patient," he said.

But for many patients, like Phyllis Toole, the delay is longer than a few days.

Phyllis suffers from rheumatoid arthritis, a condition where her body attacks her joints. When her doctor wanted to put her on Orencia, her insurance company HAP said she needed to first try a less expensive drug, Humira.

But Phyllis's doctor was worried about possible side effects and thought Humira could be risky.

After battling for months, Phyllis says the whole thing made her feel more like a number than a patient. With her doctor and insurer in a standoff, she was forced to rely on samples of the drug she got from her doctor. HAP never approved her prescription.

"They're playing doctor, is what it feels like," Toole said. "They're saying this is what you can have for the symptoms you have. It may make you sicker, but this is what you can have."

In a statement, HAP said:

Due to HIPAA laws and out of respect for our members' privacy, HAP cannot comment on specific health information of individuals. However, it's always in the best interest of everyone for the patient to get the best care as quickly as possible. This includes having access to the medication that is best able to control their condition, based on clinical evidence.

Step therapy is a process designed to make sure the patient is getting the most effective medication at the most reasonable cost. Step therapy is common practice not just with commercial insurers, but also with Medicare and Medicaid – programs that fall under federal government oversight.

Insurers are obligated not to discriminate when determining coverage. When an employer purchases specific coverage for its employees, for example, insurers by law must adhere to those rules of coverage for everyone in that group.

If a request for a specific drug or treatment is denied, HAP notifies the member and the physician of the robust appeals process, which is in place to protect the consumer. This appeals process makes sure that a variety of medical experts are reviewing the case and making determinations based on clinical evidence as well as the patient's personal history.

Depending on the type of insurance plan the individual has, this appeals process may include an independent review by the Michigan Department of Insurance and Financial Services (DIFS).

HAP adheres to these appeals processes and makes our members aware of them because we take our members' rights very seriously and we want to make sure they are getting the care and treatment that will provide the best health outcomes.

Minnesota Coronavirus Cases

Data is updated nightly.

Confirmed Cases: 37624

Reported Deaths: 1503
CountyConfirmedDeaths
Hennepin12150785
Ramsey4805226
Stearns234519
Dakota228690
Anoka2180107
Nobles16626
Olmsted110115
Washington106940
Mower9452
Rice8357
Scott7004
Clay58538
Kandiyohi5701
Wright4565
Blue Earth4532
Todd4002
Carver3641
Lyon3092
Sherburne3075
Freeborn2900
Steele2281
Watonwan2160
Benton2143
St. Louis17715
Martin1635
Nicollet15912
Cottonwood1340
Goodhue1298
Winona12215
Crow Wing10612
Pine1030
Le Sueur981
Chisago971
Otter Tail931
McLeod880
Carlton850
Dodge840
Polk812
Chippewa781
Unassigned7637
Isanti720
Itasca6412
Waseca640
Douglas620
Meeker611
Morrison591
Murray580
Becker550
Faribault550
Jackson550
Sibley542
Pennington500
Pipestone371
Mille Lacs342
Renville322
Wabasha310
Brown302
Rock300
Yellow Medicine300
Beltrami290
Fillmore280
Houston250
Swift211
Norman200
Wilkin203
Redwood180
Cass152
Wadena150
Aitkin140
Big Stone140
Kanabec141
Koochiching141
Roseau130
Marshall120
Grant100
Lincoln100
Pope100
Mahnomen81
Clearwater70
Hubbard60
Lake60
Traverse50
Lac qui Parle40
Stevens40
Red Lake30
Kittson20
Cook10
Lake of the Woods00

Iowa Coronavirus Cases

Data is updated nightly.

Confirmed Cases: 30377

Reported Deaths: 720
CountyConfirmedDeaths
Polk6332179
Woodbury320644
Black Hawk219658
Buena Vista170711
Linn124282
Johnson12388
Dallas123529
Marshall104119
Story7513
Pottawattamie71911
Scott71910
Wapello70530
Crawford6752
Muscatine62444
Dubuque62122
Sioux4600
Tama46029
Wright3771
Louisa36013
Jasper32117
Plymouth3135
Warren2641
Dickinson2602
Washington2349
Hamilton1871
Webster1712
Cerro Gordo1471
Boone1451
Clarke1292
Clay1280
Allamakee1264
Mahaska11517
Shelby1140
Clinton1051
Poweshiek1048
Carroll931
Pocahontas931
Bremer916
Des Moines862
Henry863
Franklin840
Cedar811
Emmet800
Taylor790
Cherokee751
Monona740
Floyd702
Marion680
Hardin670
Guthrie644
Sac630
Benton621
Jefferson590
Osceola590
Jones560
Harrison530
Humboldt531
Lee532
Butler522
Iowa510
Buchanan501
Monroe506
Hancock490
Calhoun482
Delaware481
Madison422
Lyon410
Clayton403
Davis391
Fayette370
Mitchell370
Winneshiek370
Mills360
Palo Alto360
Grundy350
Kossuth330
Lucas304
Greene290
Howard290
Chickasaw280
Jackson270
Union270
Winnebago270
Ida230
Cass210
Appanoose203
Keokuk201
Page200
Van Buren190
Worth170
Audubon161
Adair150
Ringgold150
Decatur110
Montgomery102
Wayne100
Adams80
Fremont70
Unassigned70
Rochester
Clear
71° wxIcon
Hi: 85° Lo: 68°
Feels Like: 71°
Mason City
Clear
69° wxIcon
Hi: 89° Lo: 66°
Feels Like: 69°
Albert Lea
Clear
70° wxIcon
Hi: 88° Lo: 68°
Feels Like: 70°
Austin
Clear
72° wxIcon
Hi: 89° Lo: 68°
Feels Like: 72°
Charles City
Clear
70° wxIcon
Hi: 87° Lo: 66°
Feels Like: 70°
Hot and sticky fourth of July weekend
KIMT Radar
KIMT Eye in the sky

Latest Video

Image

Alternative baseball hopes to come to the Med City in 2021

Image

FOURTH OF JULY IN AUSTIN AND STEWARTVILLE

Image

Seans 6pm Weather 7/4

Image

Fans excited for Honkers return

Image

Honkers fall to St. Cloud in home opener

Image

Baseball returns to the Med City

Image

Seans 10pm Weather 7/3

Image

Leaders advocate for the homeless

Image

Fireworks Show During the Pandemic

Image

Pillars of the City Unveiled

Community Events