Dr. Lisa Arkin: Wisconsin passed step therapy reform — now we need the federal government to do the same
November 14, 2019
By: Dr. Lisa Arkin in The Cap Times
On the first day of medical school, I took a sacred oath to “first, do no harm.” Above all, our role as physicians is to relieve suffering, carefully assessing in every treatment decision the delicate balance between risks and benefits. This requires clinical experience and medical knowledge of disease pathophysiology. But it is the available evidence that is paramount in our clinical decision-making as physicians. Clinical trials are created explicitly to evaluate the safety and efficacy of treatments before they are made available to patients. They provide the highest quality evidence to enable physicians to carefully weigh their risks and benefits in any clinical scenario.
However, an insurer practice called step therapy has been restraining physicians from carrying out their role by restricting treatment options for patients. Step therapy is when an insurance company forces patients to try and "fail" alternative medications decided by the insurer before covering the cost of the prescription that their physician has prescribed. This typically requires patients to fail less expensive medications first. In some cases, step therapy flies in the face of the available medical evidence, potentially endangering patients, frustrating physicians and other health care providers, and in the long run incurring greater costs for the health care system.
Thankfully, this year the Wisconsin Legislature passed, and Gov. Tony Evers signed Senate Bill 26 to reform step therapy in Wisconsin. The bill took effect on Nov. 1. I applaud the work of the bill sponsors, Sen. Alberta Darling and Rep, John Nygren, and all of the many advocates who came together to get this passed.
But it’s not enough. In order to protect all Wisconsin patients, we must pass step therapy reform on the federal level as well.
The "Safe Step Act" (S.2546/H.R. 2279) would offer common-sense protections to ensure patients have timely access to the medications prescribed to them by their health care providers by putting guardrails around the practice, and would provide patients the same protections that have been enacted in more than two dozen states across the country including Wisconsin. We need both state and federal legislation in order to cover plans that are regulated by varying state and federal agencies.
I am grateful to U.S. Reps. Mark Pocan, James Sensenbrenner and Ron Kind for cosponsoring the "Safe Step Act," and I urge the rest of the Wisconsin congressional delegation to likewise support this needed protection.
The practice of pediatric dermatology can be complicated and diverse. Although many of my patients have similar skin conditions, the severity of their disease varies widely. Severe cases are rarely just “skin limited,” and are often accompanied by other medical problems. Symptoms of itch and pain can be debilitating. The stigma of having a highly visible chronic skin disease can be significant. Based on the literature — factoring in the patient's age and other complicated medical conditions, I determine a course of care based on the highest quality evidence available for this specific population.
But without reform, step therapy means that some of my patients are denied the medications that are safest and most effective, in favor of a less expensive, often riskier drug. Only after failure — which can mean different things for different patients depending on the insurance plan — are they granted access to the medication I originally prescribed. In the most severe cases, this only delays care and increases costs to the system, since these patients are likely to get there anyway.
I believe it’s the responsibility of all of us in health care to be economic stewards in the system. Whenever possible, I prescribe the most cost-effective medication when it is also safe and likely to be effective. But not all patients are square pegs that fit into square holes. For the most unique and severely affected patients, the “round pegs” so to speak, the available evidence, combined with my own clinical experience, should outweigh the insurer’s desire to cut costs.
I’m thrilled that lawmakers from all sides, along with patients, providers and insurers, worked together to achieve step therapy reform in Wisconsin.
I am hopeful that the Wisconsin congressional delegation will continue to put patients first by supporting step therapy reform on the federal level. In spite of the gains in Wisconsin, it’s clear that federal step therapy reform is a critical next step to protect our sickest, most vulnerable patients.
Dr. Lisa Arkin is a pediatric dermatologist in Madison.