Step Therapy Is Not a Cost Solution

 Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at NYU Grossman School of Medicine in Manhattan in New York City. 

In an interesting development, the state of Illinois recently passed a law signed by the governor to ban so-called step therapy. I doubt I have to explain to most of you watching what that is, but for the few who may not know, this is a requirement imposed by insurance — third parties, who have not seen the patient — to basically say that you have to try intervention X, be it a medicine or some type of physical therapy, before you go to the more expensive procedure that you may feel is best for your patient.

It basically might be called, "try this and you can only go to the more expensive intervention if you fail." It's a fail-first policy. 

The governor— I think rightly — said, insurance has started to use this in a predatory manner just to make money and routinely turn down requests, even in the mental health area for institutionalization in a crisis, to say, we have to save money and you must do what we say first. 

At the end of the day, it's easy to target the insurance guys and the managed care guys and say that they're just out looking to maintain the bottom line. It's easy. I'm going to do it, too, because I think it's true. 

I think this step therapy requirement is inimical to good medical practice. The doctor should know what is best for their patient. The doctor is responsible for prescribing appropriately and weighing out a course of care that makes sense. 

If insurance or someone else doesn't like that, they should not be interfering with the treatment plan. They could come retrospectively, perhaps, and audit to see whether some percentage of people seem to be using things that aren't effective or didn't work out, and then use education to try to reform behavior.

I have no problem with people saying that you ordered the expensive thing, but it turned out it didn't work all that well. Maybe you want to reconsider next time. You tried it on 10 people, and it didn't work. 

Inserting third-party people who don't see the patient absolutely strikes me as interfering with what being a doctor and having your patient's best interest should be about.

It's offensive in mental health settings when that occurs. People are so desperate and it's so important to get them the maximal type of response, particularly in a terrible crisis, that I think it almost borders on criminal to let step therapy dominate what's going on there. 

In many other areas of healthcare, saying, "You've got to try this, stay in pain, be dysfunctional, and not get relief until you fail it, and then we'll move you on to what your doctor thought was the best thing for you," is not the way to achieve either good care for patients or cost containment in the US healthcare system. 

It's true our costs are out of control, but step therapy by third-party interference is not the way to redress prices or costs that need to be brought down. I'm all for doing that, but this tool is not the way to go.

https://www.medscape.com/viewarticle/step-therapy-not-cost-solution-says-ethicist-2024a1000hw2