The following was originally published in Patriot-News on November 8, 2022
Every cancer diagnosis is complex. While translation of scientific discovery into clinical practice is a reality that has led to declines in cancer mortality, not all populations benefit equally, and significant barriers exist.
We are fortunate that Pennsylvania recently took steps to decrease a barrier that many cancer patients face in receiving effective, affordable treatment. With Gov. Wolf’s signature on SB 225 reforming step therapy practices, Pennsylvania has secured a victory, ensuring patients gain quicker access to potentially life-saving medications prescribed by their physician.
Step therapy, also known as “fail-first,” requires patients to first prove they cannot use a similar, less expensive medication before insurance will cover the cost of the drug their doctor prescribed. This is of concern as the fail-first approach can significantly undermine the oncology team’s ability to most effectively treat cancer and can also negatively impact quality of life.
In reforming step therapy practices, Pennsylvania has made it so that experiences, like that of Donald—an American Cancer Society Cancer Action Network (ACS CAN) volunteer–can be avoided.
A Pennsylvania native, Donald was just seven years old when he was diagnosed with acute myeloid leukemia. The good news is that his treatment plan, which included full body radiation, cured his cancer but left him with lifelong complications, including a thyroid that stopped functioning. Thankfully, Donald was subsequently administered an effective medication to manage his condition. Yet when Donald’s health insurance changed, the new plan forced him to “try and fail” with other drugs for a month, despite his physician’s strong objection.
None of the new medications that Donald was forced to try were as effective as the drug he’d been taking at his physician’s recommendation. Tragically, he developed new side effects and required additional medical appointments as he continued to struggle with the ineffective regimen.
After “trying and failing” on this new medication Donald was finally permitted to return to his original prescription at which time he faced additional challenges readjusting and recalibrating to the medication. All said, the needless “try and fail” mandate negatively affected Donald’s health and quality of life, induced undue stress on his family and ironically increased the cost of care through the additional visits.
Unfortunately, Donald is not the only patient who has faced this situation. According to a 2019 ACS CAN survey, 1 in 3 (34%) cancer patients and more than half (56%) of physicians reported having to wait for an insurance plan to approve a cancer treatment, test or prescription drug because of utilization management policies resulting in delayed patient care. In an American Medical Association survey, 90% of physicians reported prior authorization had a somewhat or significant negative impact on patient clinical outcomes.
These kinds of arbitrary delays put patients’ health in jeopardy. I am grateful that the health of my fellow Pennsylvanians—Donald included—will no longer be at risk due to such delays.
SB 225, now Act 146, will help make this process more transparent and efficient for doctors and patients alike.
The new law does not eliminate prior authorization or step therapy practices but, rather, requires health plans to adhere to independent clinical guidelines when setting any step-therapy protocols and maintain a time-sensitive exceptions process for patients and providers to use should they feel step therapy would harm the patient’s health. These changes will make it easier for patients to quickly get the best treatment for their individual health needs, avoid potentially harmful delays in care and lessen the administrative burden for physicians.
Treating cancer is hard enough. The process should not be rendered even more difficult through capricious and confusing insurance rules which gamble with the health of individuals surviving cancer.
I am thrilled that Pennsylvania lawmakers and Gov. Wolf agreed and made it so that the lives of Donald and others are better and their access to care improved.
This is a victory for Pennsylvanians, and I celebrate that our lawmakers in Harrisburg did what was best for patients across the state.
Karen E. Knudsen, MBA, PhD, is Chief Executive Officer of the American Cancer Society Cancer Action Network.