Stepping Away From the Agonizing Overuse of Step Therapy

For many of the 54 million Americans who live with a rheumatic disease, simple tasks such as walking up a flight of stairs can be painful and challenging endeavors. To manage disease symptoms and help make activities of daily living safer and easier, patients often turn to rheumatologists like me, who can prescribe treatments that provide relief.

But despite my years of intensive study and clinical expertise, my ability to diagnose and treat my patients quickly is too often hindered by insurance utilization practices such as step therapy that are geared more toward having policyholders use medications on negotiated formularies than providing evidence-based care. Left unchecked, step therapy can have dangerous consequences for individuals battling chronic illnesses like rheumatoid arthritis, lupus and psoriatic arthritis, which is why rheumatology leaders are calling on Congress to implement commonsense safeguards that will protect our patients.

According to a recent national survey conducted by the American College of Rheumatology, almost half (46 percent) of rheumatic disease patients were required to undergo step therapy within the last year, including 59 percent of young men ages 18-29. Many patients are subjected to step therapy multiple times throughout the course of their treatment. A 2016 survey by the Arthritis Foundation revealed that nearly 25 percent of patients who switched insurance providers were required to repeat step therapy with their new carrier, and in 39 percent of the cases, step therapy was stopped because the drugs were ineffective.

When patients cannot readily access treatments that work, they are more likely to suffer poor outcomes such as prolonged pain and faster disease progression, further limiting mobility, independence and the ability to live a healthy, full life. Research shows that patients with rheumatoid arthritis whose treatments were delayed — as a result of step therapy or otherwise — for approximately four months had significantly more joint damage when compared with patients who started treatment within two weeks of being diagnosed. 

As physicians, we went through years of extensive training and swore an oath to put patient health first. Step therapy undercuts our medical expertise and interferes with our imperative to do no harm. 

My professional judgment is based on what I believe will improve outcomes for each of the individuals I treat. This means assessing each patient on a case-by-case basis, taking the time to understand his or her past medical history, concurrent medications and allergies, and potential risks that different treatment pathways pose. Forcing step therapy on patients erodes the expertise of medical professionals and makes it needlessly difficult for patients to access medically necessary treatments.

Thankfully, congressional leaders understand the harmful impact of “fail first” policies and have taken steps to protect patients with the recent introduction of the Safe Step Act (H.R. 2279 / S. 2546). Recognizing that step therapy is not appropriate for many patients, the bipartisan legislation would create a clear, transparent process for patients with employer-sponsored insurance to seek exceptions to step therapy protocols. 

Moreover, the Safe Step Act would require insurers to consider each patient’s unique medical history, as well as the physician’s medical expertise in partnership with their own, before denying patients the medically necessary treatment they were prescribed. Finally, the legislation would establish a reasonable timeframe to override insurer decisions so that patients can receive the care they need.

 It is imperative that Congress pass the Safe Step Act so that patients can once again have confidence in their ability to access the treatments their physicians prescribe. 


Angus B. Worthing, MD, FACP, FACR, is a practicing rheumatologist and member of the board of directors for the American College of Rheumatology.

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