NORD supports policies that protect patients by reforming step therapy processes.
Step therapy, often referred to as “fail first,” is a utilization management practice where insurers (public or private) require patients to try one or more alternative medications before they can access the treatment originally ordered by their doctor. While intended to control health care costs, step therapy is increasingly applied with little regard for individual medical histories or vital treatment needs, as determined by the patient’s physician, increasing the risk of patients experiencing harmful consequences.
When used inappropriately, step therapy protocols can delay necessary treatment and lead to adverse reactions that ultimately can harm the patient and increase health care costs, not lower them.
For patients with rare diseases, the impact of inappropriate step therapy is especially severe. These individuals often endure years-long diagnostic journeys before finding a treatment that works. Forcing them to deviate from an established and effective therapy undermines and can negatively impact their health and recovery. For example, patients who switch insurance plans may be required by their new insurer to go off a successful treatment and take a less effective medicine, jeopardizing their stability and, in some cases, their health outcomes.
As the use of step therapy has increased, states have a critical role in ensuring these practices do not interfere with timely and appropriate care. It is important to note that in seeking to reform step therapy protocols, NORD does not advocate for ending the practice of step therapy entirely. Instead, the goal of these reforms is to safeguard patients from unnecessary risks and delays and ensure health care decisions remain in the hands of patients and their providers, while enabling health plans to achieve the cost-saving benefits when appropriate.
To date, a majority of states have instituted step therapy protections to help patients obtain the care and treatment they need at the right time. In general, these protections:
It is important to note that state lawmakers do not have authority over all forms of health insurance, but for the purposes of this report, this analysis of step therapy protections focuses solely on state-regulated health insurance plans.
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