Opinion: Fixing ‘Step Therapy’ can help solve pain crisis

The Gold Dome. (Bob Andres/bandres@ajc.com)

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The Gold Dome. (Bob Andres/bandres@ajc.com)

Chronic pain and how to treat it in the midst of the opioid epidemic has been a topic of national importance for quite some time now – and rightly so. But missing from the national debate has been the role insurance companies can, and should, play in covering non-opioid treatments for pain.

To save money, health plans often require people to “fail first” by trying and failing on therapies other than what their physicians have prescribed. This process, called step therapy, can mean weeks, months or even years without appropriate treatment. Meanwhile, people like me continue to suffer the symptoms of chronic disease and even unwanted side effects of the insurer-preferred medications.

Georgia has the opportunity this year to join more than 20 other states which have put guardrails around the step therapy process by empowering physicians to exempt patients when medically necessary and ensuring that therapy protocols are based on clinical guidelines developed by independent experts instead of just the cost for an insurance company. Under the sponsorship of Rep. Sharon Cooper (D-Marietta), the State House passed this legislation and it is now up for consideration in the Senate.

As a legislator, I want step therapy reform for my constituents and for every Georgian. But I’m also fighting for it because this issue is real and personal for me, just like it is for too many other Georgians who live with chronic illness.

I’ve lived for the past 19 years with systemic lupus, which ranges from mild to life-threatening. Last summer, lupus led to a bulging disc in my back. I woke up every day for several weeks with a gnawing headache and chronic back pain, which kept intensifying. I was eventually sent to the ER, as the high level of pain had raised my blood pressure to the point of a potential stroke.

My physician prescribed a nerve block injection to relieve the pain and allow me to continue traveling for legislative business. But the nerve block injection was denied by my insurance. My physician attempted try and appeal the decision, but it was denied.

I was told over and over by the insurance company that I must go to physical therapy for at least six weeks before the injection coverage would be considered.

After living another week in excruciating pain, I asked the lobbyist representing the insurance company to help. Several days later, I received a call from my insurance carrier that the injection procedure was approved.

I am appalled that I had to leverage my role as an elected official in order to bypass step therapy and receive pain relief. I am angry because people I know will have to live in pain and choose to either suffer in silence or try and self-medicate.

Our health care system is not just broken; it’s wrong. It’s time for our state to start lifting barriers and hurdles that hurt the sick. It’s time to move our health care system beyond empathy into fairness and equity.

We can start by reforming step therapy.

Rep. Kim Schofield (D-Atlanta) represents District 60 covering southeast Atlanta.