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Insurers denying some costly treatments patients need

Written by Diane Archer

Bob Tedeschi reports in Stat news on a growing trend by health insurers to deny some costly treatments doctors say patients need and require them to try less costly treatments first. It’s called “step therapy.” The goal of keeping health care costs down is reasonable, but the consequences for some patients can be serious. (Note: If you’d like your insurer to cover whatever reasonable and necessary care your doctor recommends, sign up for traditional Medicare if you’re eligible.)

Step therapy at its best is arguably a good thing. There is no reason for patients to get newer treatments that are more expensive when older less costly treatments are available. But, step therapy presents a serious problem when insurers use it as a way to save money even if the older less costly treatments are not working. And, insurers are becoming “more aggressive” about making patients wait long periods before insurers will cover more costly treatments.

In some cases, doctors know that their patients need particular treatments because they have tried other treatments that have not worked. Yet, that will not stop some insurers from requiring step therapy. As a result, many states have enacted legislation to block insurers from making patients try treatments that their doctors know won’t work.

To be clear, no one is suggesting that insurers should pay for more expensive treatments when less expensive treatments work. However, insurers should not be requiring patients to try treatments when there are risks to so doing. For example, when patients switch insurers mid-treatment, the new insurer might require their doctors to drop their current course of treatment and retry treatments that have already failed.

What is to be done? More transparency about insurer practices is critical, including how they define whether a treatment has failed. And, insurers should not be allowed to require patients to retry treatments that have already been determined to fail. Speedy appeals of insurer denials are also needed, especially when people’s lives and well-being are hanging in the balance.

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  • I agree with the article. Step therapy appears to be “penny wise but pound foolish”. The goal of treatment of any medical treatment is to fix the medical issue as completely and quickly as possible. If that means going to a more “expensive” treatment, so be it. As I am a transparency fanatic, I totally agree with transparency in how an insurer makes a decision. I also agree that the appeal process must occur quickly

  • Hopefully, the fact that health insurance companies are throwing tantrums and some are even leaving the ACA, will hasten the arrival of single payer health care.

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