The Bottom Line: Step therapy
Updated: Monday, July 28 2014, 10:12 PM EDT
ALBANY -- Imagine going to your doctor for treatment, having him or her prescribe what they say is the most effective medication, but then being told you can't have it.
Critics say insurance providers are forcing patients to fail first, by making them take generally less expensive medications.
Scott Daly of Rotterdam says that happened to him, after contracting HIV in 1986.
"I had gotten HIV from a fiance who had a blood transfusion, and she passed away in 1989," Daly tells CBS 6's Dori Marlin.
On top of his HIV treatment, he still takes many other medications for side effects - including high cholesterol.
He says it took him and his doctor 7 years to figure out which script was the most effective, finally settling on Crestor.
His cholesterol numbers were looking really good, he says, until one day there was a surprise when he picked it up at the pharmacy - a change in the medication.
It was a generic script - not changed by his doctor, but by his insurance provider.
And it was part of the practice that's grown to be known as "step therapy."
"Step therapy is exactly as it might sound," says Dr. Charles Argoff, who specializes in pain management at Albany Medical Center. "It's being required by, let's say, an insurance company who pays for care for that person, to go through steps that might be failures."
So for example, if you're dealing with migraines, your doctor might tell you the best course of treatment is to take Relpax. It's a brand name, and likely more expensive. But your insurance company might say, no, you have to take a generic version instead. And if that doesn't work, another generic. And possibly another. Essentially, critics say, the company makes you fail first - before finally allowing you to take what your doctor recommended.
In his line of care, Dr. Argoff says he sees it all the time.
"Nerve pain due to diabetes, nerve pain due to chemotherapy, chronic lower back pain," he says, just to name a few.
Other common medical issues affected by step therapy include lyme disease, multiple sclerosis, epilepsy, even mental health.
They're not better therapies being mandated, says Dr. Argoff, they're just generally less expensive. But because they're also less effective, the costs can add up over time.
"For a switch in medication, you have to pay a $10 or $20 co-pay depending on what your plan is," Daly explains.
For him, between changing medications and dosages, it added up to an extra $60 in a year.
Daly says he and his doctor finally convinced his insurance company to allow him to change back to Crestor.
But for both Daly and Dr. Argoff, they say the physical cost of step therapy is a much steeper one.
"Like a carrot on a stick, it's being held up saying 'You can't have this' until you fail these other things," Dr. Argoff argues. "We have to be able to have a dialogue in such a way that we stop this nonsense."
To try to curb step therapy at least partially, state lawmakers in New York introduced legislation this past session that would give doctors a clear process to appeal the protocols, and limit the amount of time that a patient could be forced to try another medication.
That bill got stuck in committee, however. Sources now tell Dori, it will be re-introduced again next year.