"Step therapy" insurance rules for biologics not always fair to psoriasis patients

The high cost of biologics and other specialty drugs, and insurers' efforts to rein in their costs, was the subject of a Wall St. Journal article the other day (paid registration may be required to view article), but the article only told part of the story.

Specialty drugs include biotech and other drugs for serious diseases such as cancer, multiple sclerosis and inflammatory maladies such as rheumatoid arthritis. The average prescription for these medicines runs more than $1,500 and some top $100,000 a year. By contrast, conventional brand-name pills for problems such as high blood pressure, high cholesterol, and depression run roughly $90 to $120 a month.

The article also included a chart indicating that the average monthly prescription cost for specialty drugs to treat "inflammatory conditions" (of which psoriasis is one) rose 4.6% last year to $1,547.97--and that increase was actually much smaller than the increase in prices for specialty cancer and MS treatments.

To combat this trend, Express Scripts and Medco say they are tightly managing their formularies with rules governing drug selection, usage and dose. Medco is enforcing what it calls step therapy rules, says Tim Wentworth, president of its Accredo unit. Patients are required to start treatment on the lowest-priced drug first, advancing to more expensive alternatives only if and when the cheaper drug fails to work.

We have several complaints, not with what the article says but with what it does not address. The article totally ignores another strategy used by some insurers--increasing co-pays on specialty drugs to make these treatments prohibitively expensive for patients. It ignores the great health benefits many patients have enjoyed with these therapies. And it ignores the "dark side" of so-called "step therapy." Here is part of what we wrote to the author and WSJ Editor about this:

With some insurers, step therapy in practice means requiring less effective and more dangerous drugs based solely on price, rather than on any balance of cost and benefit or safety to the patient. In psoriasis treatment, this can mean forcing patients to use the Korean War-era chemotherapy drug methotrexate, despite its known risks to the liver and, for women of child-bearing age, abortion-inducing properties. The biologics are finding a market precisely because past treatment options for many diseases were so inadequate.

The article closes with a very interesting concept:

Aetna Inc., the big Hartford, Conn., health insurer, is exploring a "pay-for-performance" strategy in which a drug's price would be tied to efficacy. "Some people have spectacular results" taking pricey biotech drugs while "others have no results," says Edmund Pezalla, national medical director of Aetna Pharmacy Management. The idea, already being tried in Europe, is to negotiate drug prices based on whether a patient responds to a treatment. While details are scarce, some companies provide rebates in cash for product if patients don't achieve the desired therapeutic benefit.