Running head: POLICY ANALYSIS 1

Policy Analysis

Esperance Namahoro

Briar Cliff University

March 31, 2017

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Outline

Step Therapy or Fail First

Thesis Statement: Requiring a covered person to follow a step therapy protocol may have

adverse and even dangerous consequences for the covered person, who may either not realize a

benefit from taking a particular prescription drug or may suffer harm from taking an

inappropriate prescription drug.

I. Step therapy is impacting patients with chronic conditions and it can lead to death.
A. Assuming that one medication fits all it is just not fair for those people who might have

completely a different result from the medication.

B. The house is trying to pass a bill called HF 233 & SSB 1072, or Step Therapy or Fail First,

which will give patients access to the correct medications and limit the use of step therapy.
II. The importance of the problem historically is the cost of health care thats unaffordable for most.
A. Patients are being forced to try the cheaper treatments, even when health care providers are

confident the inexpensive treatments will not work.

B. Find ways to limit the use of step therapy.
III. the opportunities the policy will provide is the best service for patients
A. Patients will be able to get access to the right treatments
B. The health care will save money by giving patient the right medication at first try.
C. Exceptions process transparency.
I. The covered person shall have access to clear, readily accessible, and convenient

process to request a step therapy override exception

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`Description of Historical Background of the Policy

Senate Study Bill 1072/House File 233: What is Step Therapy or Fail First?

Problems That Led to Original Creation of the Problems Historically

Step therapy is impacting patients with chronic conditions and it can lead to death.

Problems that led to the original creation of the policy include the expenses of health care for the

American people. Americans are paying more money then any other health care in the world.

According to Sarah Kliff, Americans are spending $ 2.8 trillion on health care annually (LAST

NAME, 2016). Because of the unaffordable health care for most people, insurance companies

wanted to create something that is affordable for patient. Sarah Kliff emphasizes that Most

American doctors arent paid on whether they deliver the improved health, their income largely

depends on whether or not they performed the surgery, regardless of patient outcomes. (January

20, 2015). doctors job should be to care about the outcome of their performance, and they

should be responsible on making sure their patients get the right treatment at the right time.

The importance of the problem historically is the cost of health care thats unaffordable

for most, and patients end up being prescribed cheaper medicine to try to see if it works before

they are given the right one. According to Sara Kliff, In 1999, the Institute of Medicine

published a seminal report titled To Err is Human, which estimated that at least 44,000 patients

and as many as 98,00 die in hospitals each year as a result of medical errors (kliff, 2015).

This is an essential issue that led to step therapy or fail first. Step therapy is a type of prior

authorization, in most cases, patients must first try a less expensive drug on the Medicare

prescription drug plans formulary that has been proven effective for most people with the same

condition (ehealth medicare, 2016). Assuming that one medication fits all it is just not fair for

those people who might have completely a different result from the medication. The house is
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trying to pass a bill called HF 233 & SSB 1072, or Step Therapy or Fail First, which will give

patients access to the correct medications and limit the use of step therapy.

Step therapy or Fail First requirements are used by health plans to control the order and

use of prescription drugs. A patient may be required to try, and then fail on lower-cost or older

drugs selected by their health plan before coverage is granted for the drug prescribed by the

patients health care provider (National Association of Social Workers). Patients are being

forced to try the cheaper treatments, even when health care providers are confident the

inexpensive treatments will not work. For patients living with serious or chronic illness,

prolonging ineffective treatment (and delaying access to the right treatment) may result in

possible progression of disease, loss of function, and adverse effects. This may ultimately lead

to increases in unnecessary health care costs associated with additional provider visits, ER visits,

hospitalizations and other costs (National Association of Social Workers).

Step therapy was introduced on January 23, 2017. House File 233 by the

subcommittee on human resources. Representative Joel Fry and other subcommittee members

that recognized the need for such legislation in their state said:

Step therapy protocol means a protocol or program that establishes a specific sequence in

which prescription drugs for a specified medical condition and medically appropriate for a

particular coved person are covered under a pharmacy or medical benefit by a health carrier

(National Association of Social Workers).

This bill is an important step towards protecting the rights of Iowans from delayed access

to effective and safe treatment. Iowa will join multiple states across the nation that have enacted

similar legislation, including Illinois, Indiana, Missouri, New York, Mississippi, California,
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Kentucky, Arkansas Connecticut, Maryland, and West Virginia to support the limitation of step

therapy (CSRO, 2017).

Health insurance companies are constantly looking for ways to hold down costs. Since

the Americans health care system is unaffordable for many. Because of the amount of money

patients have to pay insurance companies, the companies are frequently implementing

requirements that patients step through older, less expensive therapies before being given

access to more expensive drugs when two medications are equivalent (Wilcox, 2015).

Step therapy have several names, Insurers companies call this step therapy, but

millions of people in need of prescription therapies call it something far more: fail first (Wilcox,

2015). Because of how step therapy is hurting patients, many states have raised a national

movement to stop it from hurting patients.

Legislative history of HF 23 & SSB 1072 includes Therapeutic switching (or

Therapeutic substitution)- The insurer substitutes less expensive medications or alternate

medications. These are not the medications prescribed by the doctor, and the patient is not aware

of the change until he or she arrives at the pharmacy to pick up their medications. Step therapy is

dangerous because patients are being put to cheaper medication that might not work when they

are expensive medication available that is proven to work. For example, a cancer patient whose

doctors recommend step therapy might experience negative outcomes. Referring to the national

center for Health Statistics, 76.5 million Americans report pain lasting at least 24 hours (2009).

Many of these people have endured significant distress in finding appropriate treatment for their
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pain. not only does step therapy harm patients, it is causing them to pay for medication that

wont do any good to them.

The parameters of the problems are that Fail first protocols are extremely inefficient for

patients. According to Coalition of State Rheumatology Organization, Patient who are

diagnosed with diseases such as Lymphoma, Epilepsy, AIDs, are being adversely affected

(CSRO, 2017). What fail first does is very unethical; switching medication on a patient who has

cancer might result in tremendous pain or even death for the patient.

Description of The Problem That Necessitated the Policy

The parameters of the problem include people who are living with chronic illness and

cannot afford to waste time on their health plans preferred medications if they are ineffective.

The population thats more affected by this policy is the Americans who attend doctor visits

regularly. Referring to the White House Council of Economic Advisers, Americans are not

equal health-care spenders, there are a handful of patients who use lots of medical service-and

tens of millions of people who barely go to the doctor at all (Kliff, 2015). Based on the articles,

it seems like everyone will get impacted at some point by step therapy if there are no actions

taken to stop it.

Nature, scope and magnitude of the problem is that doctors and insurance

companies are making policies that impact patients in a negative way. The goal of the doctor

should be to satisfy the needs of the patients, but with step therapy, it is the opposite. Every

patient should be able to receive the service without having to take ineffective medicine that is

doing more harm than good.

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HF 233 is the product of significant negotiations between patient advocacy groups,

insurance carriers and others. According to Kathleen A. Arntsen,

Army of advocates have fought for this bill because it improves the safety and efficiency

of such protocols by establishing guidelines to guarantee health care providers have a

standardized expeditious process to override step therapy when it is medically in the best interest

of the patient not to require failure on another treatment (Arntsen ,2016).

it is clear that more people stand with this bill to make sure patients get the treatments

prescribe.

As dermatologist Margaret Persons notes, Its frustrating to be forced to delay

the care of a patient due not only to the time involved with the authorization process, but also

when, after the steps (Justin McDaniel). The amount of time that is put towards step therapy

protocol is wasteful when the whole bill is burden to many. Failing to consider the unique needs

and preferences of individual patients, and assuming step therapy should be used by all is very

unethical. when a patient has been stable and doing well on a certain prescription, they should

keep taking it, without switching for the one that is ineffective.

Description of The Policy

One of the opportunities the policy will provide is the best service for patients, making

sure they are satisfied with their medication. It takes a lot of money to pay for health care, and it

is not getting any cheaper. With the baby boomers getting older, the population is going to need

health care now more than ever. If insurers minimize the use of step therapy, it is going to save

money economically. Since hospital stays, the procedures and long term care, and medications
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are hardly affordable, it is going to save money in the health care field. instead of switching

meds to test which one works, patients can just get the medicine that fits their condition. As the

Step Therapy in States article states,

Some physicians who treat conditions such as plaque psoriasis and rheumatoid arthritis

have argued that more traditional medications, which are often required under step therapy, are

less effective compared to biologics and often result in their patients experiencing unwanted and

unnecessary side effects (McDaniel, 2016).

Based on this article, limiting the use of step therapy process will unsure that Iowans can

gain timely access to necessary medication.

Expected short and long term goals and outcomes of the the policy include saving money

through health care, since the American health care system is very expensive. The long term

outcome of HF 233 SSB 1072 is that it will reduce patient conflicts and increase positive

treatments, where every patient gets the medication to heal their disease without going trough the

process of fail first.

The administrative auspices under which the policy is lodged under health care and

insurance companies since they are the ones using step therapy. Responsibility also falls upon the

health care professionals because they will have responsibility at the highest level to make the

change. Also the Iowa house member hold power regarding HF233, since they will determine if

the bill will pass or not.

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The funding mechanism for the policy: Step therapy was brought up by patients who are

not satisfied with their medication. Also patients who are terminal ill and are given the wrong

medication by insurance companies and doctors

The agencies or organizations with overall responsibility falls under health care

providers. However, pharmacies and insurance agencies are required to make sure patients are

receiving the right treatment.

Formal or informal criteria to be used to determine the effectiveness of the policy

includes, less patients complaining about the outcome of their medication and less patients

returning to the hospital after they have received their medication. Also implementing guidelines

on step therapy protocol in favor of immediate coverage of the prescription drug selected by the

health care professional.

Expected duration of policy- Step therapy was introduced in the house since 3-2-17. And

it is expected to last until health care starts following the guidelines patients are advocating for.

Knowledge or scientific grounding on which the policy rests includes, evidence

supporting this policy is shown through the growth in health spending, and other organizations

that have already taken steps towards preventing step therapy, such as National patient advocate

foundation, CSRO organization, American College of Rheumatology, and so on ( Motheral B.R.,

2011)

Policy Analysis
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Indications that the goals of the policy are legal are it does not infringe on anyones rights

other than promoting ones health. Referring to one of the articles as it states, any delay in

proper treatment can result in severe complication (Motheral B.R, 2011). It is clear that this

policy has nothing that will impact individuals in a negative way.

Indication that goals of the policy are just and democratic are this policy is simply

working towards protecting the patients rights. It is not inflicting on anyones rights. Also it is

not for Democrats or Republicans overall.

Indication that the policy will contribute to greater social equality are this policy not only

will help patients, but it also will help the United States save money that goes into health care.

Fail first Hurts report notes, patients who are living with chronic illness cannot afford to

waste time on health plan preferred medications if they are ineffective (Motheral B.R. 2011).

In analysis of the quotes above, restricting the use of step therapy will help patients.

Indications that the policy will affect the redistribution of income, resources, rights, and

entitlements are that this policy has a goal to advocate members of the health care field to start

giving the right treatments to patient.

The indication that the goals of the policy will adversely affect the quality of the life of

the target population or group are the goals of this policy are not only to raise awareness to

protect the quality of an individuals life, but also will work towards providing efficient treatment

for those people who are diagnosed with different diseases.

Indications that the policy will contribute to positive social relations between the target

population and overall society are this policy will make a difference for the patients and the
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insurance companies that give out medication, it will promote a better relationship. In Bob

Tedeschi view she notes, doctors and patient advocacy groups said insurance companies often

insist on step therapy regardless of past medication failures (2016). If insurance companies stop

forcing medication that does more harm then good, they wont be a problem.

Indications that the policy is effective or efficient, this policy has been proven to be

effective because more representatives voted for this policy, including Chris Hall a representative

of Sioux City whos working with other members of the house to stop insurance companies from

using step therapy. All in all, Bill 1072/House File 233: Step Therapy or Fail First, is going to

make a difference for patients and it is going to help save money in the health care field.

Limiting the use of step therapy is a better solution for patients because it will protect

individuals right.
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References

CSRO. (2017). Step therapy legislative update: Iowa fail first advocacy day. Coalition of State

Rheumatology Organization. Retrieved from

http://www.csro.info/app/document/19797260

Arnsten A. Kathleen. (2016). Egregious insurance practice jeopardizes patients health.

CRAINs. Retrieved from http://www.crainsnewyork.com/

EHealth Medicare (2016). What is prior authorization, step therapy, and quantity limit. EHealth

Medicare. Retrieved from https://www.ehealthmedicare.com

Kliff, Sarah. (2014). 8 facts that explain whats wrong with American health care. Physician for

A National Health Program. Retrieved from http://www.pnhp.org/

McDaniel, Justin. (2016). Step therapy in the states. The Council of State Governments.

Retrieved from http://knowledgecenter.csg.org/kc/content/step-therapy-states

Motheral B.R.. (2016). What is fail first? and why it matters. Fail First Hurts. Retrieved from

https://failfirsthurts.org/ffh/

National Association of Social Workers. (2017). Iowa social policy &advocacy. National

Association of Social Workers. Retrieved from http://www.nasw-heartland.org/

RSD Outreach Awareness. (2009). American Pain Foundation-Position Statement on Step

Therapy and Therapeutic Switching. Retrieved from http://rsdoutreach.4rumer.net

Daily rise (2016). Fail first: patients explain how step therapy violates doctor-patient

relationship. Rising. Retrieved from https://patientsrising.org

Wilcox, Jonathan. (2015). How step therapy tramples patients: guest commentary. Los Angeles

Daily News. Retrieved from http://www.dailynews.com

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