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August 12, 2025 • 14 mins
Aug. 12, 2025 - New Yorkers prescribed expensive, name-brand drugs may have to try cheaper alternatives before they get what the doctor ordered, as the result of insurance practices. We discuss how this process could be more transparent and have stricter rules with Ashira Vantrees, director of legal strategy and advocacy at Aimed Alliance.
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Speaker 1 (00:04):
In order to control costs, the American medical system will
sometimes promote step therapy or a fail first model, where
a patient needs to try certain medications before an insurance
company will cover what a healthcare provider may have actually
prescribed in the first place. The system is designed to
promote less costly alternatives before using more expensive but similar options.

(00:24):
To discuss an effort to curtail this practice, which is
the subject of recently adopted laws as well as pending
legislation here in Albany, we're joined on the Capitol press
room by a share of Vantrees, director of Legal strategy
and Advocacy at the Aimed Alliance, a nonprofit health policy
organization whose commercial supporters include a number of pharmaceutical and
biotechnology companies. Welcome to the show, a Shia, thanks so.

Speaker 2 (00:47):
Much for having me.

Speaker 1 (00:49):
Well for starters, I've seen studies that suggest health plans
use step therapy in about forty percent of their drug policies,
but about ninety percent of prescriptions filled in the US
are for generic drugs, which tend to be those lower
cost alternatives and thus maybe not subject to step therapy,
which is usually involving, say, a more expensive name brand drug.

(01:11):
So given that backdrop, how prevalent is the issue of
step therapy, particularly here in New York and are there
cases where it's more commonly used than others.

Speaker 2 (01:21):
Yeah, So it's kind of a difficult question to answer
because one of the biggest challenges I think we see
in health insurance in general is lack of transparency on
the use of these tactics. We definitely see step therapy
primarily used with specialty drug we are often high cost
medications used to treat complex and chronic conditions. So there's
not a hard and fast number that we see and
to give us kind of information on how often these

(01:43):
policies are used, but we know what is very often
for individuals living with chronic conditions.

Speaker 1 (01:48):
And what are your thoughts on the status quo? Is
it a net positive because ultimately it controls costs and
people eventually get the medication they need. Are are there
long term and net negatives? How do you think of
the system from your perspective?

Speaker 2 (02:07):
So, I think there's really two challenges. Is that we
completely understand that health plans are trying to both mitigate
costs and also ensure patients are getting access to the
most effective treatments, But The challenge with policies like step
therapy is we often see without protections at the state
level in terms of state legislation. These policies can be
inconsistent with clinical base guidelines, can result in patients waiting

(02:27):
several weeks or even months to get access to the
appropriate treatment. And the bigger challenge I think from the
consumer perspective is that we hear anecdotally a lot from
patients and caregivers and family members about the challenge of
step therapy and how it's actually not cost effective for them,
and how it can increase their costs in terms of
hospitalization or disease progression and in some case irreversible disease progression,

(02:49):
And so patients are often the ones making this case
of how harmful this practice is. On the other side,
we don't really see health plans having to justify how
big the cost savings are with the use of these programs.
That's one of the things that we've been working on
at AIMED Alliance is to work with the state legislator
to pass additional legislation to have that be a reporting
requirement for health plan for them to demonstrate how much

(03:10):
cost savings are actually being derived from these policies. And
we just released a report at Aimed Alliance called our
twenty twenty five Step Therapy Report, which looks at trends
in step therapy oversight practices in AI and Connecticut has
recently passed some similar legislation and has this reporting about
how much plans are actually saving with the use of

(03:30):
step therapy. And so for their twenty twenty three reports,
or excuse me, their twenty twenty four report, which uses
their twenty twenty three data, they have a breakdown of
how much each plan was saving from other utilization management
policies which includes step therapy, and on average it's about
four dollars and fifty cents per beneficiary a month, which
is about fifty dollars a year per beneficiary. And so

(03:51):
I think there's a really good question that now that
we have this data, we can ask ourselves, is this
really a cost effective tool and our consumer's willing to
pay that extra fifty dollars annually to have avoid all
of these challenging processes that can be more detrimental than
helpful to their health.

Speaker 1 (04:05):
So let's get into that idea of transparency and cost savings.
Would you want to leave it up to the insurers
to determine what might be a cost savings, because I
have to imagine there are different ways to calculate the
different costs that they might incur, and from one perspective

(04:26):
the savings could be trivial, but then maybe calculated in
a certain way, the savings could be really significant. So
is that part of the so called guardrails you're looking
to put in place, or are you kind of agnostic
when it comes to something like the.

Speaker 2 (04:41):
As the specific kind of equation to determine what is
savings that's going to be left up to the legislator
or implementing authority in terms of the Department of Financial Services,
we think, but really what this legislation focuses on is
getting kind of more of that big picture data and
reporting requirements out there, because right now there's not even
any reporting requirements as the savings at all. The need
whether that's looking at a per beneficiary or on an

(05:03):
annual basis, or if there's more savings for specific conditions
compared to others, all of that is unknown, and so
I think it would be difficult to say the exact
type of measurement we want for this to be deemed
an effective cost shaving measure until we start getting some
of that initial data in there. And that's really I
think the goal of that transparency legislation is to give
more information to legislators so they can start making more

(05:25):
informed decisions about how to make these programs more sustainable
for patients and consumers in the long run.

Speaker 1 (05:32):
So, obviously, the insurers have an interest in keeping costs
down and that's clearly what motivates them for something like
step therapy. And if I was a much more cynical person,
I would look at the commercial supporters of your alliance
and say, well, your interest is solely in pushing these

(05:54):
more expensive drugs. Your supporters on the commercial side include
some big names that people know, like Pfizer and some
other names they probably don't know but should know. So
how would you respond to that cynical person who might say, well,
you're just trying to sell more expensive drugs.

Speaker 2 (06:11):
Yeah, I know, I completely understand that concern. We are
a nonprofit organization and so our policies are based on
our mission, which is to protect and enhancements of healthcare
consumers and providers, and what we're hearing from individual that
we're working with in New York. So we're leading a
coalition in New York of patients and providers and advocates
who have been harmed by sex.

Speaker 1 (06:29):
But just to point out, I don't think those patients
are necessarily paying the bills for your organization. I have
to imagine it's those commercial organizations that are probably paying
the bills for your nonprofit.

Speaker 2 (06:42):
Well, I mean, we do have commercial supporters, which we
publicly disclose our website, so we're not trying to hide
anything by any means. But like I said, our policies
and priorities are set by our independent board of directors,
and I think our work in New York too, it
really has to derive from talking with patients improviders about
the challenge they have. And I think there's a misconception
off and put on individuals chronic conditions that you know

(07:03):
they have a preference for certain medications, when in reality,
what's happening for many of these patients is that they've
already tried and failed on these medications, but without appropriate guardrails,
they can be required to try and fail on that again.
And so for them, they know that it's going to
be a relapsed in symptoms that can be time up work,
and all of these other consequences that aren't often calculated
when we're talking about cost savings directly for insurance. I

(07:24):
think in Connecticut's report as well, you know, let's say
they're saving an average if I think it was on
average fifty dollars per beneficiary per year, right, But that
wasn't looking I was just looking at the health bend savings.
It wasn't looking at any sort of additional consequences health wise,
had the consumer experience from not getting access to their
medication probably or cost of the healthcare provider for dealing

(07:45):
with these more administrative side of things. So it really
was siloed and not looking at the holistic impact of
these programs financially. And I think one of the reasons
our work in New York Is has been so effective
is because we've been working with paid sheets and providers
to make sure that the solutions are really hitting that
middle ground of making sure that there is a mechanism
for health plans to continue to use step therapy, but

(08:08):
also ensuring that there is a mechanism to ensure that
it's based on clinical based evidence and providers have a
means of overriding these step therapy policies when they're inconsistent
with the patient's clinical symptoms or clinical based guidelines. And
that's really how we got to that guardrails legislation that
you had mentioned, is after the twenty sixteen law was

(08:28):
passed to New York, we worked with patients and providers
to understand how the twenty sixteen step therapy law that
created exceptions for step therapy was being implemented and how
consumers were benefiting from it. And we found that there
was just a lot of gaps in the law just
because of really small things like if a health plan
wasn't responding to an exception request within a time period,

(08:49):
there was no mechanism for that to be deemed in
automatic approval. And so it's one of the things we
went back to the New York legislator and talked about
and said, Okay, this original law can be so much
more effective for consumers just by having this language I
know that says when a health plan has not responded
to the exceptional question, you know, the provider is doing
everything on there and to comply with those requirements, they
get an automatic approval, right, And we want to hold

(09:10):
everyone in the system accountable and I think those are
really easy ways to do that, and those solutions have
been drive from patients and providers well.

Speaker 1 (09:18):
Sticking with solutions that have been pushed in the past,
there was a bill that was approved in twenty twenty
four with some changes in twenty twenty five, which we're
supposed to ensure that patients aren't going to have to
repeatedly try and fail with the same medications over and

(09:39):
over again. When you think about a law like that
one where it was recently adopted so you might not
see it fully play out by now, how does something
like that need to be enforced to ensure that it
is effective. Is this something where you're turning to the
state Department of Health? Is this about the Department of
Financial Services, given their oversight insurance companies. What is the

(10:01):
state's role in making sure these guardrails are effective.

Speaker 2 (10:08):
Yeah, I think that's definitely a huge challenge we see
with these these laws across the country. The Department of
Financial Service is the appropriate kind of regulatory for this
because it is health insurance in the state regulator markets.
But one of the challenges we see with these legislation
and New York isn't I think unique in any way,
But is that accountability for these laws is so dependent

(10:30):
on consumers filing complaints with like the Department of Financial Services,
And that can be a really big lift for consumers,
especially when you think of that someone who's already undergoing,
you know, a process where they're trying they're not feeling well,
they're trying to gas is the right medication. Now they
have to file the internal appeal, the external appeal always
to the consumer complaint, which can be weeks or even months,
and by the time they get there and through that process,

(10:53):
and that's why we're really we're trying to work with
the New York legislator to get these additional transparency and
reporting requirements because we believe that, you know, once we
have this data, then the Department of Financial Services can
start using it to look at, Okay, are we seeing
any specific bad actors in this space? Are we seeing
any conditions that are being unfairly targeted in a discriminatory manner,

(11:13):
and then they can have you know, additional steps being taken,
whether that be additional legislation, additional regulation, but really starting
with the importance of that data is kind of the
gap that we're missing and really empowering the Department of
Financial Services and other state agencies to proactively monitor the
enforcement of these laws.

Speaker 1 (11:30):
Well, sticking with that idea of transparency, would your organization
be supportive of some of the drug pricing transparency initiatives
that are championed by groups like the ARP, which represents
seniors in New York.

Speaker 2 (11:45):
Do you have a specific drug pricing.

Speaker 1 (11:47):
Off the top of my head, I can't come up
with one, but I know that they've made the case
that there needs to be more disclosure about how expensive
it is to make drugs, because that's one of the
things we often hear is being aroundale for why name
brand drugs are so expensive that there's all this research
and development or ensuring that these companies have to disclose

(12:09):
how much they might be making from something or their
ability to go buy generics and not necessarily be limited
to name brands in certain situations and certain medical plans. So,
sticking with that theme of transparency more broadly without necessarily
weighing in on any specific bills, do you think that
it makes sense to have transparency more broadly to have

(12:29):
it on the drug side of things as well.

Speaker 2 (12:32):
Yeah? Absolutely, But I think the entire system needs to
create transparency, and I want to make sure too, we're
not only looking at pharmaceulal companies but also PBMs. I
think PBMs play a huge role in prescription drug costs,
and we really do need more transparency about how they're
connected to all the different parts of the problem and
where there may be perverse incentives to do things like

(12:52):
keep the cost of prescription drugs high in order to
ensure that there's better rebates. You know, one of the
challenges I think we often see with step therapy as
well well, is that step therapy policies aren't necessarily based
on clinical based guideline sometimes, and so it's hard to
reconcile how certain drugs are being selected for a step
therapy policy, and so I think that raises questions and
concerns about is this placements only based off the rebate

(13:13):
that the PBM is getting or things like that. I
don't think we have the clearest of answers that, just because,
like you've said, there's a lot of stakeholders within the
healthcare supply chain who don't have enough transparency, and I
think if we start demanding that transparency, we'll have a
lot more information to make the appropriate decision so we
can make long term changes for our healthcare system on
behalf of consumers.

Speaker 1 (13:32):
Well, we've been speaking with a share of Van Tries.
She is the director of legal strategy and Advocacy for
the nonprofit health policy organization Aimed Alliance. Sher, thank you
so much for making the time. I really appreciate it.

Speaker 2 (13:44):
Thanks so much.

Speaker 1 (13:52):
And for more Capital Pressroom content, visit Capitol Pressroom dot
org or wherever you download your favorite podcasts.
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