Legislature could help millions with debilitating health conditions

Advances in modern medicine have precipitated a revolution in the treatment of chronic health conditions. Californians diagnosed with rheumatoid arthritis, for example, are no longer given the expectation that the progressive disability will end in a wheelchair.

Californians will only reap the benefits of these scientific breakthroughs, however, if the legislature takes common-sense action now to ensure that all patients can have access to the treatments their doctors think best.

Current cost containment measures in California health plans force patients to try and fail on up to five different, cheaper and often ineffective medications before they agree to cover the treatment originally prescribed by the patient’s doctor.

This practice, known as “step therapy” or “fail first,” is designed to force patients to try less effective medications in the hope they’ll respond favorably. For many Californians, this practice can severely impact a patient’s health and well-being, and unnecessarily prolong their treatment. For those living with arthritis and other forms of rheumatic conditions, these unnecessary delays are not only cruel, but can be dangerous.

According to the U.S. Institute of Medicine, more than 100 million people in the United States are affected by chronic pain every year, which is more than the number of Americans who are affected by cancer, heart disease and diabetes combined. In the state of California, more than 20 percent of adults (or roughly 5.3 million residents) and 38,000 children have doctor-diagnosed arthritis. This painful, costly and potentially disabling autoimmune disease not only damages joints, but can also rob people of the opportunity to live life to its fullest.

When patients are denied access to treatment, every unnecessary trip to the doctor or pharmacist can mean additional missed work, which in turn drives up costs for California businesses through lost productivity and increased insurance premiums. Step therapy can also drive up the direct costs to the California health care system through unnecessary hospitalization or emergency room visits. Arthritis and other rheumatic conditions cost the state $7.8 billion in medical expenditures and $4.3 billion in lost earnings.

Fortunately, patients who don’t respond to other medications or who have aggressive diseases now have options. Scientific breakthroughs are revolutionizing the treatment of arthritis and new therapies have the potential to minimize or prevent disease progression and even induce remissions. But Californians living with arthritis and other painful and chronic conditions will only benefit from those breakthroughs if they are allowed timely access to the course of treatment their doctor thinks most appropriate.

Any potential solution to the dangerous step therapy problem must begin by addressing those patients who are forced to endure weeks, if not months, without treatment. The number of “steps” should be limited to only two before patients allowed to access the treatment prescribed by their doctor. Any solution should also require health plans to have an expeditious process in place for step therapy exceptions.

In this critical era of health care cost containment, a common-sense solution to step therapy would preserve it as a tool for California insurers, but also keep decisions about how best to treat patients in the hands of their doctors – a win-win for the California health care delivery system.

Federal health reform does not do anything to address egregious step therapy practices, so enactment of a common-sense step therapy solution will have no impact on how the health law will be implemented in California.

All Californians – including the 5.3 million Californians and 38,000 children living with arthritis, the millions of additional residents managing multiple chronic conditions, and any Californian being treated for a medical condition that might fall victim to dangerous step therapy protocols – deserve treatments that their doctors think are best.

Dr. Wesley Mizutani is Chair of the California Arthritis Foundation Council.

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