As a psychiatric nurse practitioner providing medication management for patients with mental illness, I frequently find myself filling out paperwork or arguing with insurance companies to try and get needed medications covered for my patients.
While I understand that most patients can and should be treated with cheaper medications before moving to the more expensive ones, I think it should be up to the judgment of the clinician, not the judgment of the insurance company. This process, called step therapy, often burdens the clinician and does not allow them to prescribe a medication that they think is the best fit because they know that insurance companies will not cover it.
Patients who have more treatment-resistant forms of illness or have other health concerns (i.e. diabetes, obesity, high blood pressure, pregnancy, etc.) are more likely to be affected because the cheaper versions of medications may not be safe to try.
For example, antipsychotics are a well-established treatment for treatment resistant depression. One of the major side effects of older, cheaper antipsychotics is weight gain. Patients who are already obese or have diabetes should avoid this side effect if possible. Some of the newer antipsychotics are much less likely to cause weight gain, but, because of step therapy, we usually required to try the older antipsychotics first, to “prove” that they need the newer antipsychotics. Often, this means two medication trials and the patient will gain weight with each, which exacerbates their diabetes or obesity. By the time they can try the newer ones, significant harm has been done.
Although the short-term effect is that it takes longer to get them on an effective medication, the long-term effects can be devastating, as they have gained additional weight and lost control of their diabetes. I’ve seen this play out several times in my practice at the expense of the patient. I had one patient who had severe, treatment-resistant depression. He had failed trials of multiple antidepressants and was about to lose his job because he couldn’t function at work. He was obese and had diabetes.
I wanted to start Abilify, an antipsychotic that has been shown to be very effective for treatment-resistant depression. His insurance company denied it and said that it was a “Tier 3” medication, meaning he had to fail trials of two other medications before they would approve it. I started Seroquel, another antipsychotic that has a much higher risk of weight gain but is also effective for his mood. He gained 15 pounds in two weeks while taking Seroquel and his blood sugar increased dramatically, while his metformin dose (a medication for diabetes) had to be increased by his primary care doctor.
We then tried risperidone, another antipsychotic with moderate risk for weight gain, and he didn’t gain weight but got severe dizziness and fell and injured his wrist. After I filled out more paperwork to show that he had failed trials of two other antipsychotics, treatment with Abilify was finally approved.
It worked well to improve his depression with no weight gain, his diabetes eventually got back under control and he was able to go back down on his dose of metformin. I was worried that these side effects would happen with the other medications, which is the reason I wanted to go straight to Abilify, but I had to put him through the weight gain, dizziness and an injury before his insurance would pay for Abilify.
If the patient has not had the right number of failed medication trials, it can take months to get their medication since they have to try and fail medications in between and they are often only seeing a provider once a month. While most patients would do fine on the cheaper medications, as a clinician, if there is reason to believe that a more expensive medication would better treat the symptoms, they should have the flexibility to start with that medication.
I urge the Legislature to support efforts to put controls into place regarding Step Therapy practices. The Interim Health and Human Services Committee heard testimony from those providers and patients adversely affected by this practice during their meeting Sept. 20. Anyone who has been affected by this practice should reach out to the committee to voice those concerns between now and the 2018 session.
Sara Webb is a psychiatric nurse practitioner and adjunct faculty at the University of Utah. She received her bachelor’s of nursing at Brigham Young University and her masters in nursing at the University of Utah.
