Volume 38, Issue 3, Fall 2019
Michael A. Santoro
The Ethics of Insurance Industry Step Therapy Policies
A Medical Profession Ethics Approach
Step therapy is an insurance company policy whereby patients must try a less costly treatment and fail-first before the insurer will cover another, more costly treatment. This article argues that (1) there are relevant and well-established principles of medical ethics—the duty to practice evidence-based medicine and the duty to consider cost-effectiveness when treating patients—that constrain and guide physician behavior with respect to step therapy; (2) clinical practice guidelines (CPGs) promulgated by authoritative physician groups attempt to incorporate and reconcile the competing demands of evidence-based and cost-effective medicine, although it is unclear whether they do so in a manner that appropriately considers all relevant ethical factors relating to cost-effectiveness; and (3) despite the potential shortcomings of CPGs, the ethical principles guiding and constraining physician behavior can help demarcate the ethical boundaries for other actors in the drug prescribing and reimbursement matrix, including insurance companies and benefit managers.