Opinion: Patients Shouldn't Have to Fail First

A doctor’s prescription should reflect what is best for the patient, not what checks the right box on an insurance company’s protocol. Yet for millions of Americans living with chronic and complex conditions, medical judgment is overridden by step therapy. This practice requires patients to first try insurer-preferred treatments before receiving coverage for the medication their doctor prescribed. These “fail first” policies force patients through unnecessary hurdles and delays before they can access the treatment the healthcare professional determined was right for them.

A new national survey shows just how strongly voters want that system reformed. Among 1,400 likely voters, 70% oppose insurance companies enforcing step therapy mandates. Understandably, 90% also said they trust the advice of their own doctor before their insurance company to determine which medication is right for them.

Healthcare is personal. A physician knows a patient's medical history, previous treatments, how they might react to potential side effects and managing that individual patient’s chronic condition. An insurance protocol cannot fully account for every individual circumstance. Yet, insurance companies have the final say on prescription approval. According to page five of the survey, 32% of participants said an insurer had either denied prescription drug coverage for them or a family member or required an alternative to the medication their doctor prescribed. For households where someone regularly takes prescription medication, that number rises to 37%.

Americans are understandably concerned about experiencing the same problem themselves. Congress has an opportunity to address that concern through the bipartisan Safe Step Act. This bill establishes a clear and standardized exceptions process for patients covered by applicable employer health plans. It does not prohibit step therapy, but rather allows patients to clearly understand why their provider might suggest another course of treatment and includes protections for patients and their doctors. Exceptions would be available under defined circumstances, including when the required treatment has already failed, when delaying the prescribed treatment could cause serious harm, or when a patient is already stable on their medication.

The legislation would also establish timelines for insurers to respond to exception requests—usually within a few days or even 24 hours in urgent circumstances. Those are reasonable guardrails that recognize the need to manage healthcare costs and the reality that standardized insurance protocols are not a one-size-fits-all policy.

The Safe Step Act also had wide bipartisan support. The survey found that 78% of likely voters support the reforms contained in the Safe Step Act, including 78% of Republicans, 80% of Democrats and 75% of independents. At a time when Congress is entrenched behind party lines, those numbers are significant. Step therapy reform is not an ideological battle over the entire healthcare system. It can be about something much simpler: making sure patients have a timely way around an insurance requirement when their individual medical circumstances warrant it. This approach is commonsense and puts patients’ health at the center. 

More than 30 states have already established some form of step therapy exception process. However, state protections generally cannot reach self-insured employer health plans governed by federal law. The Safe Step Act addresses that gap.

Patients should not have to prove that the wrong treatment fails before they can access the treatment their doctor believes is right for them. The Safe Step Act offers Congress an opportunity to put reasonable limits around that process while preserving an insurer's ability to manage benefits. Patients and physicians from both political parties support this bill. Congress should take up the legislation and give patients a clear, timely path to the treatment their healthcare professionals recommend.

Patsy Writesman is the owner of ManageHealthCareCosts.com.