Step therapy, also known as fail first, is a common practice used by insurance companies to minimize costs by requiring patients to try less expensive treatments before providing coverage for more expensive options. While this practice may appear to be cost-effective, it can have negative consequences for patients, particularly those suffering from Overactive Bladder (OAB). According to experts, step therapy for OAB imposes burdens for patients and can lead to suboptimal treatment outcomes. This article aims to highlight the challenges that patients face due to step therapy for OAB and the potential ramifications on their health and well-being.
In an interview, urologist A. Lenore Ackerman, MD, PhD, discussed the use of step therapy in treating overactive bladder (OAB), a topic she explores in her paper “Penny-wise but Pound-foolish: The hidden costs of step therapy for overactive bladder.” Ackerman explains that insurance plans often require patients to try a less expensive generic medication before they can receive a more effective branded therapy, leading to limitations in treatment and adverse events. She refers to OAB treatment guidelines from the American Urological Association, which recommend a stepwise approach to therapy, starting with behavioral and fluid management, and moving to medication if necessary. Unfortunately, step therapy requirements by insurance companies often prevent clinicians from prescribing the most effective medications for OAB, leading to frustration and burdensome administration processes to overcome these restrictions.
Ackerman highlights the significant consequences of these restrictions on patients’ ability to receive proper care, the quality of their care, and their overall health and wellness. Even when patients receive the proper medication, they may encounter hidden long-term costs. These costs may include delays in receiving care and appeals for authorization, higher out-of-pocket costs, and potentially negative long-term side effects. Regarding the latter, Ackerman discusses concerns about cognitive impairment from long-term use of anticholinergic medications.
Moreover, Ackerman explains how step therapy requirements impose significant burdens and costs on clinicians and physician practices. The requirements can increase workload and necessitate hiring additional staff, negatively impacting how the practice operates while potentially reducing the quality of care provided to patients. Psychologically, these requirements can lead to frustration and reduced professional satisfaction for clinicians.
In response to these concerns, Ackerman recommends improved communication and education between clinicians and insurance companies, transparency in insurance coverage of OAB treatments, and a reevaluation of the criteria used to determine which patients require step therapy. Ultimately, clinical and economic evidence should guide treatment decisions for OAB, rather than the demands of insurance companies. Ackerman’s suggestion is for a collaborative approach to OAB treatment decisions, ensuring better outcomes for patients and clinicians alike.
In conclusion, step therapy for OAB may seem like a cost-effective solution for insurance companies, but the burden of trying multiple medications and potentially delaying effective treatment falls squarely on the shoulders of patients. As healthcare providers, it is our duty to advocate for the best interests of our patients and strive for efficient and effective treatments that prioritize their well-being. By working together, we can push for policy changes that prioritize patients over profits and improve the lives of those suffering from OAB.
