Global Healthy Living Foundation, Nyack, NY, USA.
Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, NY, USA.
Health Econ Policy Law. 2022 Jul;17(3):282-297. doi: 10.1017/S1744133121000153. Epub 2021 Apr 12.
Step therapy, also termed , describes a practice of insurance and pharmacy benefit management companies denying reimbursement for a specific treatment until after other treatments have first been found ineffective (i.e. failed). Laws to limit step therapy have been passed in 29 states of the United States. Using extrapolated data on fully insured employees, we find that except for New York and New Mexico, enacted State laws don't apply to even one-third of a state's population. Using the more robust Kaiser Family Foundation (KFF) data, which do not include fully insured employees, we find that only 2-10% of a state's population is covered. Advocating for these laws has been an expensive and time-consuming process, likely to become more so for the 21 states without such laws. The laws that have been enacted can be near impossible, to enforce, and loopholes exist. As a result, using KFF data, more than 90% of people in the United States with health insurance may still be unable to access the treatment chosen as most appropriate for them with their physician. Based on these data, we conclude federal step-therapy legislation is needed.
阶梯式疗法，也称为，描述了一种保险和药品福利管理公司的做法，即在其他治疗方法首先被证明无效（即失败）之前，拒绝为特定治疗提供报销。美国 29 个州已经通过了限制阶梯式疗法的法律。根据对完全参保员工的外推数据，我们发现，除了纽约州和新墨西哥州外，即使是州内三分之一的人口也不受已颁布的州法律的约束。使用更可靠的凯撒家庭基金会（KFF）数据（不包括完全参保的员工），我们发现只有 2-10%的州人口受到覆盖。倡导这些法律是一个昂贵且耗时的过程，对于没有这些法律的 21 个州来说，可能会变得更加困难。已经颁布的法律可能难以执行，并且存在漏洞。因此，根据 KFF 数据，超过 90%的有医疗保险的美国人可能仍然无法获得他们的医生认为最适合他们的治疗方法。基于这些数据，我们得出结论，需要联邦阶梯式疗法立法。
