Representatives from more than 45 patient and provider groups across Ohio gathered at the Statehouse on February 8 to declare this month “Fail First February” in an effort to raise awareness of the insurance industry practice known as “fail first” or “step therapy.” The Ohio Academy of Family Physicians is a member of the Coalition to Reform Step Therapy, a group comprised of patient groups, physician organizations, and pharmacists.
Step therapy is a cost savings tool used by health insurers that forces patients to take and fail on medications other than what their doctor has prescribed, before their insurer will cover the cost of the original medication.
Step therapy protocols can be harmful to patients both financially and physically, causing an undue wait for the proper treatment and in some cases a worsening of a person’s medical condition. Step therapy does not take into account an individual’s medical history or other factors, but instead relies upon a pre-determined prescription drug formulary or protocol.
“Step therapy undermines what doctors think is the best treatment for patients,” said Sarah Sams, MD, FAAFP, past president of the OAFP and current faculty at the Grant Family Medicine Residency, Columbus, OH. “Physicians prescribe medications based on their knowledge of the patient’s overall health and ability to tolerate certain medications. Physicians are finding step therapy is used increasingly, and even for generic medications. In addition, physicians are being asked to change medications that patients have been using for many years in order to try a different drug that is in the step algorithm.”
Legislation is currently underway in Ohio to reform step therapy protocols. Soon to be re-introduced from last session, the bills will give doctors a transparent and standardized process to appeal step therapy requirements for patients needing a particular treatment. The bill does not ban step therapy, or the number of steps an insurer can implement. Patients may still need a prior authorization from their insurers. Senator Peggy Lehner (R-Kettering, OH) will lead legislation in the Ohio Senate and Rep. Terry Johnson (R-McDermott, OH) will lead companion legislation in the Ohio House.
“It is my great hope that we can raise awareness of the potentially dangerous practice of ‘fail first’ protocols,” said Kenton Beachy, executive director of Mental Health America of Franklin County. “People with psychiatric disorders need to have access to the medications their doctors believe are the most appropriate for them. Improper use of medication can lead to negative and expensive outcomes such as emergency room visits, hospitalizations, possible entry into the criminal justice system, and in the most tragic examples, even death.”