The following opinion-editorial piece authored by Ohio Academy of Family Physicians Past President Sarah Sams, MD, in support of passage of Senate Bill 243 (SB 243), step therapy reform legislation, is being pitched to newspapers across the state of Ohio.
Dr. Sams was invited to author this op-ed by the Columbus public relations firm Lesic & Camper Communications who found her testimony in support of SB 243 so inspiring.
“I practice family medicine, I teach family medicine, and I advocate for family medicine. Family physicians are dedicated to treating the whole person and care for patients of all genders and every age. Unlike other specialties that are limited to a particular organ or disease, we treat the full range of medical conditions. My day might include administering well-baby immunizations in the morning and seeing a diabetic with nerve pain and hypertension in the afternoon. The ability to interact directly with my patients is why I chose this specialty, and why the residents I train have done so as well. Regrettably, that personal relationship between doctor and patient is being hampered by a slew of administrative hassles, many imposed by health insurers.
“Chief among these is “step therapy,” a tool insurers use to limit how much they spend covering patients’ medications. Under step therapy, a patient must try one or more drugs chosen by their insurer – usually based on financial, not medical, considerations – before coverage is granted for the drug prescribed by the physician. Patients may be required to try one or more alternative prescription drugs that are of lower cost to the insurer, but may not be the best therapy for some patients. Step therapy requirements vary from insurer to insurer and change frequently even within the same insurance company. These requirements result in physicians and other practice staff spending hours on the phone attempting to obtain permission to get needed medications for patients.
“My nurse manager and I recently spent two hours and fifteen minutes between us on the phone trying to get a blood pressure medication approved for an 85-year-old patient. That’s two hours and fifteen minutes we were not able to spend assessing and treating an actual patient. And the kicker? This woman had been on that exact same medication for nine years. We knew it worked for her, in combination with other medications she takes given her complex medical needs. But she had a new insurance plan and the company wanted her to try something different. I have to ask: why should the insurer’s step therapy protocol override my medical judgement based on years of seeing this patient? Why should it override a record of successful treatment with this drug? Even though we ultimately got the prescription approved, why does it have to be so hard and take so much time away from patient care?
“Legislators are now asking these questions as well. SB 243 is a bipartisan bill introduced by State Senators Peggy Lehner (R-Kettering, OH) and Charleta Taveras (D-Columbus, OH) that seeks to improve the step therapy process. It would require step therapy guidelines be developed by medical professionals. It would establish some circumstances in which step therapy is inappropriate, including cases like my elderly patient who was already doing well on her medication. It would require insurance companies to have a transparent process for appealing step therapy decisions.
“These welcome changes will benefit patients and physicians alike. I could tell you countless stories where my medical judgment and the safety of the patient have been disregarded due to step therapy decisions. Every physician could write a book about the frustration and time wasted because of these requirements – requirements that often put the patient at risk.
“Primary care physicians choose their specialty in order to be on the front lines of delivering comprehensive, coordinated care to patients. Insurance requirements and interference into the practice of medicine have become so burdensome that physicians are burned out. A recent survey of members of the OAFP indicated the severity of this problem – physicians are starting to hate what medicine has become because it is so far from why they chose to go into medicine in the first place. The joy they experienced when they actually had the time and energy to interact and care for patients is diminishing – and the burden of step therapy requirements is one of the contributing factors.
“We have to start addressing these administrative hassles in medicine or we are going to have a greater problem achieving and maintaining a sufficient primary care workforce to provide care to an aging population. The OAFP strongly supports passage of SB 243.
Dr. Sams chairs the Commission for Governmental Advocacy for the American Academy of Family Physicians.
Congratulations, Dr. Sams!