Does A ‘One-Size-Fits-All’ Formulary Policy Make Sense?

Over the last decade, insurers have increasingly used step therapy, or “fail-first,” policies as a strategy to contain pharmaceutical costs. Step therapy requires patients to begin treatment for a medical condition on a typically less expensive drug, and only progress to more costly second-line drugs when the first-line therapy becomes ineffective or inappropriate. Step therapy shifts clinical decision-making away from physicians and toward centralized policies that define treatment steps for patient populations based on the potential for more cost-effective care. The rapid growth in the use of step therapy policies in recent years—from 27 percent in 2005 to 73 percent in 2013 among employers—indicates a misunderstanding about the direct and indirect harms of this “one-size-fits-all” approach. Step therapy can delay access to the most efficacious therapies This can increase the duration of illness and raise the total cost of health care in the long-run. Delays in receiving health care, whether caused by step therapy edits or other factors, have been shown to be significantly detrimental to patient health outcomes. For example, breast cancer patients with a treatment delay of three months or more had a 12 percent lower five-year survival rate compared with breast cancer patients with only a zero to three month delay. Similarly, patients with rheumatoid arthritis who delayed disease-modifying treatment for approximately four months experienced significantly ...
Source: Health Affairs Blog - Category: Health Management Authors: Tags: Costs and Spending Drugs and Medical Technology Equity and Disparities Health Policy Lab Health Professionals Insurance and Coverage Payment Policy Quality Prescription Drugs step therapy Source Type: blogs