Insurers aren’t doctors, or, why step therapy needs to be regulated.

Doctor talking with stressed patient. Isolated on white background

This morning an alert came across my Twitter feed from the New York chapter of NAMI (National Alliance for Mental Illness) urging me to contact my state representative about a bill regulating step therapy. Step therapy is another term for fail first health insurance policies wherein a doctor must prescribe the least expensive treatment option and the patient must fail on it before the insurance company will pay for a more expensive treatment option. If you’re saying “What the hell? They can DO that?” then you’re reacting the same way I did. I’ve been fortunate that my insurance has covered all of the medications I’ve taken for my depression/anxiety and the decision on what medicine I should be taking is between me and my therapist. They may charge me differently for a name brand drug versus a generic, but there’s no real limit on what my therapist can prescribe.

I’ve gone through a few medication changes in the last year as I find what works, what doesn’t, what impact side effects of a particular medication have, etc. When I switched medications it was because neither my therapist or I felt the drug was working as well as it could or should be. Not once did my therapist ever say “I think you should be on ______, but first we have to put you on a course of _______.”

The causes of mental health/mood disorders are complex and there isn’t a pill that can make you better. Some people don’t respond to medication. For me, medication combined with therapy and mindfulness practice has me doing much better than when I was depressed. It’s a journey that’s rough at times, and I can’t imagine having it made rougher by insurance company intervention into the course of treatment.

As the NAMI alert says:

NAMI-NYS feels that medical decisions and treatment options are best made by a patient’s doctor and that it is necessary to regulate Step Therapy protocol and provide a clear and concise override process for health care providers to follow; this will allow doctors to retain their ability to prescribe from the full gamut of medications and make the decisions they believe to be best for their patients.

Anti-psychotic and anti-depressant medication are not interchangeable. Those with mental illness who are unable to access the most appropriate, clinically indicated psychiatric medication experience higher rates of emergency department visits, hospitalizations, and other health services. For people with serious and persistent mental illness providers must be able to select from a full range of drug options so as to maximize treatment efficiency, minimize side effects, and avoid drug-to-drug interactions.

The bill that they’re asking members of the legislature to support is a good first step towards regulating step therapy. While it doesn’t eliminate this type of practice, it would ease the ability of a physician to override the insurance company’s decision and limit the testing period of the more inexpensive medication.

Understand, I’m sympathetic to the fact that healthcare is expensive and that insurance companies, contrary to their public image, aren’t just out to screw people over, but to find cost-effective ways to treat them. However, the solution isn’t to interfere with a medical decision and the doctor-patient relationship. That’s why I did write a note to my representative in the state Assembly, Gary Finch. He sits on the insurance committee that will need to pass the bill before it goes to the full chamber. I hope he does the right thing and supports it, because there are other, better ways to control costs without having insurance companies practice medicine.

2 thoughts on “Insurers aren’t doctors, or, why step therapy needs to be regulated.

  1. Well said Paul! Glad that you are taking a stand for so many. Thanks!


    Liked by 1 person

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