Doctors, patients urge Cuomo to sign law that changes ‘fail first’ treatment

step therapy
Gazette photo by James Gormley
Patients and doctors held a rally at the Capitol recently to urge Gov. Cuomo to sign a bill that would give health care providers a chance to appeal step therapy protocols used by insurers. The current system often requires patients to use cheaper prescriptions first before more costly options are allowed.

Dozens of patients and health care providers lined the steps of the Capitol during a recent rally to demand that Gov. Andrew Cuomo sign a “step therapy” reform bill into law, giving patients and their doctors more power to choose treatment options.

Patients suffering from lupus, cancer, HIV/Aids, mental health, multiple sclerosis, and chronic pain were in attendance to make their voices heard in favor of the legislation that reforms the way doctors can appeal an insurance company’s “fail first” protocol.

Step therapy, also known as fail first, is a practice in which insurance companies provide coverage for cheaper drugs to patients during the initial stages of treatment. The insurance companies wait until the medication that they provide proves to be ineffective before authorizing more expensive treatments, and often require two or even three failures before doing so.

Kathleen Arntsen, president and CEO of the Lupus and Allied Disease Association, told her personal story on the steps of the Capitol as a way to demonstrate the real-life implications of insurance companies’ “fail first” policies.

She said the failure of step therapy caused her to go blind in one eye and she is in danger of physically losing it. Arntsen talked about the potential harms of the practice, saying it is unfair that patients are “forced to fail twice” before receiving the proper medication they need.

Arntsen ended her speech by chanting “ho ho, hey hey, doctors have the final say.”

Others who spoke at the rally cite evidence they say proves step therapy is harmful to patients and delays them from receiving the medication they need. Advocates at the rally also chanted “put patients first ahead of profits,” accusing health plans of focusing on the bottom line instead of patients’ health.

Another critic of step therapy, Dr. Steve Walerstein of the American College of Physicians, criticized the fact that the widely used procedure directly ignores the suggestion of doctors.

Walerstein addressed the crowd in front of the Capitol, explaining that the decision about which medications are prescribed and administered should be “in the hands of doctors and professionals who are educated.”

An overwhelming number of doctors and other health care professionals are against step therapy as it takes control of the well-being of patients away from doctors and put into the hands of those who know less and might have alternative motives.

The bill (S.3419-c/A.2834-d) is sponsored by Assemblyman Matt Titone, D-North Shore, and Sen. Cathy Young, R-Olean. It passed both houses in mid-June after undergoing several amendments. it is awaiting action by the governor.

Specifically, the bill would provide an expedited process for patients and health care providers to attempt to override a step therapy system for treating patients. If the bill is signed into law, a determination would have to be made by health plans and insurance companies within 72 hours of the receipt of all information from the patient and doctor in emergency cases.

Upon a determination that the step therapy protocol should be overridden, the health plan must authorize immediate coverage for the prescription drug prescribed by the patient’s doctor. The bill does not ban the step therapy system nor does it dictate how many steps a health insurance company can implement in its plans, but it would speed up the process for appeals.

With the passing of this legislation New York joins the states of Illinois, Indiana, Missouri, and West Virginia, all of which have passed similar bills this year.