An Interview with ACR Honoree Rep. Raul Ruiz on Step Therapy Reform

At the ACR’s Advocates for Arthritis conference in Washington, D.C., in September, Rep. Raul Ruiz, MD (D-Calif.), received the organization’s 2019 Award for Public Leadership in Rheumatology in recognition of his outstanding work on step therapy reform and other issues in support of rheumatology care.

“I was honored to receive the ACR Executive Committee Award and meet with the executive committee,” Rep. Ruiz tweeted from the event. “I look forward to continuing our shared work to empower patients in California and across the country!”

Last April, Representatives Ruiz and Brad Wenstrup, DPM (R-Ohio), introduced the Safe Step Act (H.R. 2279) in the House of Representatives. The bipartisan legislation, which amends the Employee Retirement Income Security Act of 1974, would limit the use of step therapy and offer a path for patients and physicians to seek reasonable exceptions. A similar bill, the Safe Step Act of 2019 (S. 2546) was introduced last month in the Senate.

ACR President Paula Marchetta presents Rep. Raul Ruiz with the 2019 Award for Public Leadership in Rheumatology on Sept. 12, 2019.

“Congressman Ruiz has been a champion for rheumatology issues and the entire physician community. As a physician in Congress, he understands the needs of our members and patients, as reflected in his spearheading step therapy reform, fighting for better recognition of the expert cognitive care our members provide, protecting access to Medicare for seniors and his leading bipartisan efforts to address the many other healthcare issues facing our nation,” says ACR president Paula Marchetta, MD, MBA. “We were proud to recognize and thank him for his leadership by presenting him with this prestigious award.”

Treatment Barriers
Although similar legislation has been passed in 25 states, Congressional action is still needed because employer-provided plans are regulated by federal law.

Step therapy, sometimes called “fail first,” is touted by insurance companies as a cost-control measure to reduce expenses related to specific drugs, treatments or tests. Insurance carriers require patients to try one or more medications that they prefer due to their negotiated formularies; only if the initial drug fails to work for the patient will the carrier approve coverage for the drug the treating physician selected for that patient, even if the physician is certain the insurer-preferred treatment will not be effective. This process can cause long treatment delays and place patients’ health in serious jeopardy.

Evidence of Harm
As one of 17 physician members of Congress, Rep. Ruiz, an emergency medicine physician, has advocated reforming step therapy while educating members of Congress about the practice’s negative impact on patient care.

Problems associated with step therapy have been well documented. Earlier this year, an ACR survey of more than 1,500 U.S. adults living with rheumatic disease revealed that almost half (46%) of respondents receiving treatment were subjected to step therapy by their insurance company.

A survey conducted by the Arthritis Foundation in 2016 reported similar results, with more than half of the 1,414 patients surveyed having to try two or more different drugs prior to receiving the one their doctor originally prescribed. In 39% of the cases, step therapy was stopped because the drugs were ineffective. Unfortunately, the condition of patients also grew worse in 20% of the cases, and nearly 25% of patients who switched insurance carriers to avoid the step therapy process were required to repeat it with their new insurance provider.

If the Safe Step Act is signed into law, employer-sponsored health plans will have to remove treatment barriers resulting from step therapy and provide a transparent and clear process for both physicians and patients seeking reasonable exceptions to step therapy.

Meanwhile, Rep. Ruiz is also demonstrating leadership on other issues important for rheumatologists.

“Dr. Ruiz has sent comments to the Centers for Medicare & Medicaid Services on the reimbursement rates for evaluation and management codes on behalf of physicians,” says Lennie Shewmaker, JD, the ACR director of congressional affairs. “His ability to educate and lead the current House majority party on issues is invaluable to our members and their patients.”

Looking Forward
Rep. Ruiz recently shared with The Rheumatologist his thoughts about step therapy and his motivation for supporting patients and physicians through legislation.

The Rheumatologist: What do you ultimately hope to accomplish with the Safe Step Act?

Rep. Ruiz: As a physician, my top priority is ensuring Americans have access to quality, affordable health care. A critical component of establishing quality care is to ensure the doctor-patient relationship is protected so that physicians and patients can work together to determine optimal treatment. That is why Congressman Brad Wenstrup and I introduced this legislation to ensure employee health plans include common-sense exceptions to step therapy requirements, which will allow patients to access the medications they need.

TR: What has been your motivation? With so many other pressing issues that Congress is currently facing, why is this so important to you?

Rep. Ruiz: Patients who are forced to “fail first” often don’t have the time to wait for access to treatment that works for them.  The strict step therapy protocols often require patients who changed insurance companies, through no fault of their own, to go through months of a treatment that has failed before, meanwhile their condition worsens. Patients and doctors already know what they’ve tried and what hasn’t worked, so why force them to do go through it again?

The Safe Step Act helps ensure that physicians and patients, not insurance company administrators, have the authority to make treatment decisions that are best for patients.

TR: Is there anything else you plan on doing to support this legislation?

Rep. Ruiz: I will continue working with my colleagues in Congress as well as patient advocates to bring attention to this important issue, uphold the integrity of the doctor-patient relationships, and ensure patients can access the medications they need.

Get Involved
You can do your part to rein in step therapy by asking your representatives in Washington, D.C., to join Rep. Ruiz and others in supporting step therapy reform. Go to the ACR’s Legislative Action Center to send a pre-written message to your legislators.

Carol Patton, a freelance writer based in Las Vegas, writes the Rheum After 5 column for The Rheumatologist.