Step therapy

In managed medical care step therapy is an approach to prescription intended to control the costs and risks posed by prescription drugs. The practice begins medication for a medical condition with the most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary. Also called step protocol or a fail first requirement, and is a type of prior authorization requirement.

Recent trends in prescription drug prices in the United States has led to an increased pressure on health care providers to keep down the cost of prescription medication while maintaining high levels of availability to the patient.[1] The use of generic drugs when possible allows health care plans to pursue both of these goals effectively.[2] Physicians and managed care providers may disagree on the proper step therapy[3] and patients are encouraged to become knowledgeable in managing their own care.

Opponents

Opponents of step therapy, such as Fail First Hurts, have detailed the pitfalls of step therapy.[4] "Fail First is used by health insurers to control costs. It is time-consuming from a physician and patient standpoint, is more expensive from a direct and indirect out-of-pocket cost perspective, denies patients the drugs they need when they need them, and allows payers to practice medicine without a license."

  • Creates additional barriers leading people to forgo needed medications
  • Can cause patients’ medical conditions to deteriorate, increasing the need for medical intervention in the future. As a result, patients require increasingly costly medical care
  • Increases frustration and incidents of depression
  • Increases the risk of non-compliance and self-medication

See also

References

  1. ↑ Jessica S. Banthin, Peter Cunningham, and Didem M. Bernard "Financial Burden Of Health Care", 2001–2004 Health Affairs, January/February 2008; 27(1): 188-195.
  2. ↑ Brenda R. Motheral, PhD; Rochelle Henderson, MPA; and Emily R. Cox, PhD "Investigation showing step therapy reduces managed care costs: Plan-Sponsor Savings and Member Experience With Point-of-Service Prescription Step Therapy", The American Journal of Managed Care Volume 10:457-464 July 2004 Number 7 Pt 1
  3. ↑ Neil J. MacKinnon, Ph.D., R.Ph., Ritu Kumar, M.H.S.A., R.N., "Prior Authorization Programs: A Critical Review of the Literature", Journal of Managed Care Pharmacy 2001 Volume 7 Issue 4:297-303
  4. ↑ FailFirstHurts.org

Further reading

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The Academy of Managed Care Pharmacy’s Concepts in Managed Care Pharmacy: Prior Authorization


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