Skip to content

Pushing for a Step in the Right Direction


As a dermatologist, it is my job to take the clues the skin provides and interpret these to do my very best to diagnose, monitor and treat my patients.  Insurance companies sometimes make that difficult.

I’ll share the story of one of my patients, whom I’ll call Carol.  She has severe psoriasis and psoriatic arthritis. Her skin disease is extremely itchy and affects her ability to sleep and the pain in her joints limits her ability to perform her job as a massage therapist.  Unfortunately Carol also has a rare form of blood cancer, limiting our ability to use medications that might lower her immune system.  

Our options for treatment for her are extremely limited.  Having already failed one of our less immunosuppressive medications, we switched her to a second medication that is felt to be safe in patients with a history of cancer.  Both her skin and joints responded beautifully. This was truly a life altering medication for her.

Later that year, she changed insurance companies.  Her new plan would not cover the pill we had switched her to.  Despite the fact that she was well controlled on this medication, they wanted to see her fail the medication we had already tried while she was on their plan before they’d consider covering the new medication.  

This meant discontinuing an effective medication and re-trying a medication we already knew would not work for her.  Meanwhile, she went without adequate coverage causing pain, itch and social isolation due to worsening of her disease for six months.  What makes this worse is that for psoriatic arthritis, uncontrolled disease can lead to permanent, irreversible joint damage.  

This is horrific.  It is unfair. It is bad medicine.  

I wish that I could tell you that Carol’s case was rare.  Unfortunately I, and dermatologists across the country, tackle multiple similar situations on a daily basis.  

Step therapy, also known as ‘fail first,’ requires patients like Carol to take cheaper treatments first, even if clinicians believe a different therapy is medically in the best interest of their patient.  This is a problem. Forcing patients onto an insurer-preferred formulary medication can result in increased symptoms, side effects and even relapse for patients with stable disease. It also requires physicians and patients to compromise their treatment decisions in a way that can be dangerous, time-consuming and more expensive in the long term.

It is because of patients like Carol that I, and dermatologists across the nation, are banding together with other physicians, patients and patient advocacy groups to fight on behalf of legislation that would improve the step therapy process.  Over 25 states have passed bills that would significantly improve transparency and efficiency surrounding the process of step therapy. Similar legislation has been proposed in Massachusetts, my home state, and a handful of other states this year.  

It behooves physicians to take a seat at the table and make our voices heard on policies that affect our ability to provide the best care for our patients.  Together, we can help move toward a system that puts our patients back at the center of care.

This post is part of IfPA’s “By All Accounts” blog series.  Each month, a different guest author – and a different story – adds a new piece to the common narrative of how insurance practices meant to control costs are instead hurting patients.

Related Articles