Diabetes Educators are natural advocates. We tend to be passionate about access to care and best treatment for our patients and soon to be patients. I think we all have a patient story or two that demonstrates what is wrong with our current health care system. The lack of drug or device coverage, co pays and deductibles barriers to care and the lack of reimbursement for diabetes self- management education.
The one issue that comes to my mind as a practice manager is step therapy that payers require physician practices to go through. Step therapy requires patients to take other potentially ineffective medications first, then fail on these medications before the insurance will pay for the doctor’s original prescription.
This process significantly delays effective treatment for patients and significantly increases the work load of the physician’s office staff. It can take as much as 2 hours per patient to manage the requests and appeals. This process is in place to help control costs for the insurance companies. But what it does is block patients access to medications, limits the decision making of the patients and physicians and increases the work load and burden of the nursing staff. The cost is shifted from the insurance carrier to the physician office by increasing the need for additional staff to handle the requests and denials.
Step therapy is not only used for drugs treating diabetes but also for autoimmune diseases, psoriatic and rheumatoid arthritis, cancer, multiple sclerosis, and mental health. Step therapy is on the rise and will continue to have a negative impact on our patients unless we advocate for change. It is not going to go away.
At this year’s AADE Public Policy Forum – A Local Approach with Maximum Impact, May 5 – May 6, we learned about the great work Patrick Stone, Director of State Government, is doing with the National Psoriasis Foundation in getting Step Therapy Legislation passed in States. Currently, there are 11 states with state laws that help to reduce the harmful impact step therapy has on patients. There are 13 states that have pending legislation. Montana is NOT included in either list.
What could legislation do? It could require that step therapy programs are based on clinical guidelines developed by independent experts. It could force the insurer’s process to be transparent and available to the provider and patient. It could give the decision making back to the provider and patient.
Are we ready to join with other health care professionals and patient groups to change the way step therapy is done in Montana?