I’m a nurse practitioner for the largest private neurology practice in Kansas, where multiple sclerosis (MS) is one of the top two diagnoses treated. Every day, I meet with patients to review and discuss their prognoses and decide which treatment option will best fit their needs. But then, too often, my recommendation is met with resistance from insurance companies that mandate a patient to first try a cheaper alternative to what I’ve prescribed. This practice is known as “step therapy” and it requires a patient to try — and fail — on one or more alternatives before coverage is granted for the drug originally prescribed. Essentially, step therapy pushes health care providers and their patients out of the front seat and allows insurers to take the wheel.
Fortunately, more than a dozen other states have taken notice of this harmful practice and stood up for patients’ rights. Kansas should too.
Treating a chronic condition is not as simple as selecting a medication and filling the prescription. There are several factors that must be considered when choosing a treatment for a patient with MS — potential devastating side effects, ability to manage a medication and access to care for regular monitoring — all of which have the potential to affect a patient’s ability to succeed with treatment. In fact, for some, finding the right medication can be the difference between ability and disability.This is why it is so important for health care providers, not the far-removed insurance companies, to have control over prescriptions made.
I worked with a female in her 20s who found her medicine injections painful, and therefore had trouble with medication compliance. I prescribed her an oral medication instead, but was denied by her insurance company, stating she needed to try and fail at least one to two more injectable therapies first.
After years of being stable on a daily medication, a father of three’s insurance required that he switch to a different formulation of the drug, changing the frequency he needed to take his medicine. With his work and family schedule, he struggled with this change, but his insurer would no longer cover his preferred daily version. Consequently, he has suffered from worsening of his MS to the point that he has had to give up involvement in a personal commitment.
A teacher and mother of two experienced two major relapses in one month, resulting in symptoms that made her afraid to drive or even carry her toddler. I recommended she switch to a different treatment specifically designed for rapidly progressing disease, which the insurance denied because she had not tried and failed other “cheaper alternatives.”
All of these are examples of step therapy in action. Why should an insurance company — not a health care provider — have the power to force a patient to struggle with a painful medication, change a patient’s successful routine or prevent a patient from participating in daily activities? Why are insurance companies in charge of patients’ health care?
Some argue that step therapy saves money. But with separate insurance companies covering only medication costs, they have no incentive or obligation to reduce hospital costs, testing costs, loss of work costs or other costs that can arise when a patient is not adequately managed. Step therapy does not reduce costs, it just shifts them elsewhere.
Keep in mind that I have no incentive for choosing one particular medication over another for my patient. My top priorities as a medical provider are to keep my patients safe, to be their advocate and to ensure that they are successful with treatment. Step therapy undermines my ability to take care of patients who have entrusted me with their health and well-being.
Our Legislature is currently considering a bill, Senate Bill 82, which proposes exceptions to, and a clear process for medical provider to appeal, step therapy. The passage of this bill will have a positive impact on patients across the state — those with MS as well as a myriad of chronic conditions. I urge our legislators to put in place these protections for Kansans.
Amber Wagnon joined the Neurology Consultants of Kansas as a nurse practitioner after completing her master’s degree in nursing at Wichita State University.