Asthma is complicated.  The disease poses many challenges in the diagnosis, treatment and management of the condition.  Children who live with asthma are particularly vulnerable; as their bodies develop and grow, their treatment regimen will need to adjust.  In addition, there is an increased prevalence of asthma in children living below the poverty line, and disparity in their asthma outcomes.  In Ohio, asthma is a leading cause of hospitalization and emergency department visits for children.

As a pulmonary physician, I treat children from all walks of life who live with asthma.  My training and experience allows me to help these kids live the best and healthiest they can with their asthma. Asthma can be controlled with a combination of therapies that include critical medications such as inhaled steroids.

Imagine my frustration when I am able to get a child with asthma stabilized on a medication that works well for that child, only to be overruled by a health insurance plan.  This happens, and it’s call step therapy.

Step therapy is a practice health insurers use to manage the cost of medications.  Step therapy requirements can be imposed if a doctor prescribes a certain medication, and the health plan determines a lesser cost medicine in the same class should be used first.  This is not an unreasonable concept; most doctors already prescribe the most effective medicines at the least cost to their patients.

However, there are times when a patient’s unique medical needs require a certain medication. This is when the one-size-fits-all approach with step therapy is a problem.  Asthma medications are especially prone to step therapy because health plans frequently change the list of preferred medicines they will cover.  Switching medications for a child who is stabilized on an existing regimen poses health risks and higher costs in the system when a child needs to be hospitalized for an adverse situation from switching medications.

Health plans’ step therapy requirements can be hard to understand at times.  In my practice, I have prescribed certain pulmonary medications for a toddler, only to have the health insurer insist on a lower cost medication that is designed for a teenager.  This shows me the decisions about step therapy requirements do not involved pediatricians, asthma specialists, and pharmacists who know the most about the medications.

Unfortunately, when I need to ask a health plan to suspend step therapy because of my patient’s personal medical situation, I am usually met with resistance and hassle.  My office spends a lot of time in back-and-forth with health plans to fight for the best medication we know our patients need.

The time has come to put some guardrails on step therapy in Ohio.  Right now, the Ohio General Assembly is considering Ohio Senate Bill 56 and Ohio House Bill 72 – companion bills designed to bring reasonable reforms to the practice of step therapy.  Twelve other states have passed these reforms to protect patients and ensure doctors can prescribe what they think is best.

I, and many other patient advocates representing various disease groups, are hopeful these bills pass and become law in Ohio.  The legislation does not seek to ban step therapy, but to reform the practice.  One provision in the bills allows for a more streamlined process for doctors to follow, when they need exemptions to step therapy requirements.  Another provision requires that health plans’ guidelines for step therapy be directed by medical personnel.

I have seen first-hand the impact step therapy has on children suffering from asthma and other pulmonary diseases.  Other health advocates and medical providers see how step therapy impacts patients with cancer, mental illness, diabetes, arthritis, multiple sclerosis and more.

I urge readers to call their state senator and state representative and encourage them to support Ohio Senate Bill 56 and Ohio House Bill 72.

 

Dr. Benjamin Kopp is a pediatric pulmonoligist located in Columbus.