Step down therapy

 Insurance companies will list certain drugs as “ST” or step up therapy. A patient needs to fail the formulary alternatives before “Stepping up” to a medication that isn’t covered.

I’ve been practicing a lot of “Step down” therapy, and here’s why.

With the recent economic turmoil and high unemployment rates, we’ve seen many patients in difficult financial circumstances. Many patients have lost their employer based commercial insurance plans and switched to Medicaid. Unfortunately, many providers in our community don’t take Medicaid and they end up switching care to our resident continuity clinic. This influx of patients (formerly with commercial insurance) has given me additional perspective on our healthcare system.

One of the first things we have to do with such patients is review their medication list and make changes. Most of the managed Medicaid companies have strict formularies and will not cover many brand name medications. Initially, my initial reaction was frustration. As a patient advocate, I want the power to give patients medications that I feel is appropriate, especially if they have a track record of success.

But once I began to peel away the layers of such cases here’s what I found.

I’ve seen several patients on brand name medications that had never tried generic alternatives. Some were never offered it, and some showed aversion to generics, stating they never worked as well. When I asked them how they ended up on a specific therapy, several had indicated it started out with samples in their doctor’s office. And once it was established that these brand name samples worked, nothing else was offered.

I also recall a patient who was dropped from their commercial insurance plan because he seeked overpriced out of network care at a place notorious from practicing what I would classify as fringe concierge medicine.

Shockingly, we had a patient on a brand name proton pump inhibitor, paying 75 dollars a month and never offered any of the myriad of generic options. He couldn’t have been more thrilled at the opportunity to try something much cheaper.

This is a just small skewed sampling of issues I have seen. The vast majority of such cases have great positive outcomes that meet the expectations of both physician and patient.

It think it’s great that our healthcare system provides choices for patients. That flexibility is a strength. But it comes at a price. The price is care that is subject to becoming bloated, overpriced and not evidence based.

My hope is that the medical community can continue to build trust with our patients and show them that cost effective care is just as good. What may be looked at as “step down” therapy is really a “step up” for the patient, physician and healthcare system at large.



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