AGA endorsed legislation to provide patients with a clear, equitable and fair appeals process when subjected to step therapy protocols. In step therapy, also known as “fail first,” insurers require patients to try and fail their preferred medications before covering the therapy prescribed by their health care provider. This practice jeopardizes the physician-patient relationship, since it bypasses what the physician believes is the best treatment for their patient. Although step therapy is used by insurers as a cost-containment mechanism, it has been shown to not save money in the long run due to complications that patients suffer, which can require additional physician visits, emergency department visits or even costly hospitalizations. With the increase of biologics to treat diseases like inflammatory bowel disease (IBD), more and more patients with digestive diseases are subject to this policy.
Appealing step therapy protocols can be very timely and burdensome for the physician and the patient, and can take months to resolve. The Restoring the Patient’s Voice Act (H.R. 2077), legislation introduced by Reps. Brad Wenstrup, R-OH, and Raul Ruiz, D-CA, both physicians, would provide a clear and timely appeals process when a patient has been subjected to step therapy. H.R. 2077 would require employer-sponsored health plans to:
• Establish a clear and convenient process for physicians to appeal a step therapy protocol for their patient.
• Grant patient exceptions to step therapy under five critical circumstances.
• Expedite care by requiring a timely decision for appeals —
three days or 72 hours or within 24 hours, if life threatening.
Please urge your member of Congress to take action and cosponsor the Restoring the Patient’s Voice Act (H.R. 2077) today!