It's Time to Put a Stop to Step Therapy

Pain ManagementMarch 2012
Volume 5
Issue 2

A guest editorial by Cynthia Toussaint. "If the Affordable Care Act survives the impending legal challenges and is fully implemented, it will eliminate a major barrier to health care by increasing access to care for millions of Americans suffering with chronic pain."

If the Affordable Care Act survives the impending legal challenges and is fully implemented, it will eliminate a major barrier to health care by increasing access to care for millions of Americans suffering with chronic pain.

However, many Americans will still face restricted access to needed medications due to the health insurance industry practice known as step therapy (also called “failfirst” protocols), whereby payers require that patients must first fail trials of several cheaper medications before the payer will authorize the more expensive drug originally prescribed by the patient’s physician.

There is currently a bill, AB 369 (, making its way through the legislative process in California (it recently passed the California State Assembly and is up for consideration by the State Senate) that would limit the ways in which health plans can use fail-first protocols with prescription pain medications. AB 369 would make pain relief more readily available by giving pain sufferers faster access to prescription remedies.

Many insurance companies oppose AB 369 and similar legislation, citing concerns that any limitations on the use of step therapy would “make it more difficult to manage the costs of prescription drugs” ( These companies argue that step therapy helps to drive down health care costs. Not only is this policy dangerous to patients’ health, research has shown that step therapy can actually increase the direct cost of health care in the long run (

Forcing patients suffering with chronic pain to endure weeks or months of ineffective drug therapy can turn short-term discomfort into a lifetime of suffering. In fact, when treatment is delayed, pain can turn into an intractable and intolerable disease in and of itself. As studies and research mount, many clinicians agree that nothing good can come from making a person wait for pain relief.

Unfortunately, I learned this the hard way. Although I was eventually diagnosed with Complex Regional Pain Syndrome (CRPS), for 13 torturous years my HMO insisted that the pain I was suffering was all in my head. During that time, my CRPS spread throughout my body and ravaged my vocal cords, leaving me bedridden for a decade and mute for five of those years, enduring burning, excruciating pain that felt like I had been doused with gasoline and lit on fire. With timely care, my pain might have been alleviated before exacting this terrible toll. Part of this delay came in the form of step therapy, which meant that I suffered for months, even experiencing withdrawal symptoms, including hallucinations, pain flares, and intense anxiety, while I “failed” the medications my health plan insisted I try first, over the objections of my physician.

As founder and spokesperson of For Grace (, a Los Angeles-based nonprofit organization dedicated to ensuring the ethical and equal treatment of all women in pain, I hear from women in pain on a daily basis who tell me about their pain conditions and the burdens brought on by their suffering. They also tell me about step therapy and the obstacles to access to timely, effective pain care their health plans create.

For Grace is the proud sponsor of AB 369, which will prohibit health plans from requiring patients to try and fail on more than two medications before allowing them to have the pain medication prescribed by their physician. More importantly, it also allows physicians to determine the duration of any step therapy protocol.

California State Assembly Member Jared Huffman (D-San Rafael), author of AB 369, said that “As a matter of health policy, Californians can no longer afford to leave issues as critical as patient care in the hands of bureaucrats and health insurance executives. We must instead place patient care back in the hands of physicians who are in the best position of knowing the medical history and needs of the patients.” For Grace and other supporters believe that AB 369 can be a model for the rest of the country.

Millions of Americans already suffer from chronic pain. They shouldn’t have to endure that suffering because of the misguided efforts at cost control that supersede physicians’ treatment decisions and deny patients access to needed medications. Delays turn pain the symptom into pain the disease. Let’s delay no more. Please support efforts at the state and national level to curtail or limit the use of step therapy in pain management.

Cynthia Toussaint is the founder and spokesperson of For Grace, an organization dedicated to raising awareness of gender disparities in pain assessment and treatment. She is also the author of Battle for Grace, a memoir of her experiences dealing with CRPS and the medical system. Learn more about Cynthia and AB 369 at

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