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FWD:American Pain Foundation-Position Statement on Step Therapy and Therapeutic Switching

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FWD:American Pain Foundation-Position Statement on Step Therapy and Therapeutic Switching

Post  byrd45 on Tue Feb 17, 2009 10:11 pm

Position Statement on Step Therapy and Therapeutic Switching
January 2009
The American Pain Foundation has been monitoring the impact of insurer use of step therapy and therapeutic switching and is concerned about the impact of these policies on people with pain.
Step therapy - Requires alternate medications, which in some cases includes over the counter medication, be taken before the physician recommended medication is approved for reimbursement. Patients are required to fail numerous other treatment options before the insurer will grant the patient access to the treatment option that was originally prescribed by the patient’s physician. This protocol is used as a cost-saving measure for the insurer. Step therapy often sets the stage for forced “off-label” use of medications that may no longer be appropriate nor provide optimal efficacy for an individual’s medical condition. In the long run, this policy can actually increase costs for the insurer because creating a delay in care can increase resistance to treatment or cause other health complications.
Therapeutic switching (or “therapeutic substitution”) - The insurer substitutes less expensive medications or alternate medications. These are not the medications prescribed by the doctor and the patient is not aware of the change until he or she arrives at the pharmacy to pick up their medication. These medications may have more side effects and be less effective for the person with pain. Pharmacists’ and doctors’ offices are put in the unfortunate predicament of confronting insurers in order to provide the patient with the treatment that they prescribed. This is different than “therapeutic interchange,” where exchanges are in accordance with previously established and medical staff-approved written guidelines or protocols, within a drug formulary system.
According to the National Center for Health Statistics, 76.5 million Americans report pain lasting at least 24 hours. Many of these people have endured significant distress in finding appropriate treatment for their pain. Once an effective course of therapy for their pain is found, there is often a limitation placed by insurers on the patient’s ability to access this treatment or the length of availability of this treatment. These alternative treatments are often changed by the insurer without full knowledge of the patient’s case and possible other conditions and/or drug interactions that may have factored into the physician’s choice of medicine. While doctors’ offices must contact the insurer to advocate for the pain management option they prescribed, the patient is forced to wait without the recommended medication and/or treatment until the matter is resolved.
The American Pain Foundation finds these insurer policies unacceptable and endorses legislative and regulatory policies that put prescribing power back in the hands of physicians in charge of a patient’s care. We recognize that insurance companies are trying to cut costs and avoid unnecessary medical interventions, but we must support a physician’s judgment in their patient’s care. The American Pain Foundation supports the American Medical Association’s official statement on this issue.

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