BACKGROUND: Step therapy policies that require prescribers to follow an ordered protocol for drug choices are widely used by public and private insurers to manage medication costs; however, the perceptions of prescribing physicians regarding these policies have not been studied.

OBJECTIVE: To determine physician attitudes toward step therapy policies and the correlation of these beliefs with physician characteristics.

METHODS: A sample of clinically active physicians specializing in internal medicine, cardiology, or endocrinology received a survey administered online or via mail. Five-point Likert scale questions assessed physicians’ opinions of clinical, economic, and implementation elements of prior authorization policies; physician demographic characteristics; and the extent of their interactions with the pharmaceutical industry.

RESULTS: 686 physicians (48%) responded to the survey, which was evenly divided among primary care physicians, endocrinologists, and cardiologists. Many respondents (70%) had interactions with industry, including receipt of meals or gifts and use of medication samples. Physicians reported that step therapy policies could improve the affordability of medication use (55% agree vs. 26% disagree) and its clinical appropriateness (59% agree vs. 19% disagree). By similar margins, however, physicians stated that step therapy policies were implemented inefficiently and inflexibly and often did not incorporate relevant patient-specific information. Physicians in subspecialties, especially endocrinology, and those who had interactions with the pharmaceutical industry were more likely to hold negative views of step therapy policies.

CONCLUSIONS: Most physicians recognize the potential of step therapy to improve the quality and cost-effectiveness of prescribing, although interactions with industry may affect these opinions. Physician perception of ineffective implementation of these policies, however, undermines their acceptability.

DISCLOSURES: The American Board of Internal Medicine (ABIM) funded the survey used in this study. The ABIM had no role in the design and conduct of the study or development and preparation of the manuscript. Survey honoraria was provided by the Consumers Union. Kesselheim and Avorn’s work is funded by the Laura and John Arnold Foundation. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science, Arnold Ventures, and the Engelberg Foundation. Ross is employed by the ABIM. Fischer, Lu, and Tessema have nothing to disclose.

What is already known about this subject

  • Step therapy policies are commonly used by public and private insurers to control medication use and cost.

  • The effectiveness of step therapy policies depends on prescriber willingness to provide information to payers.

What this study adds

  • Most physicians agree that step therapy can help improve medication use and cost.

  • Physicians identify significant problems with the implementation of step therapy policies that are associated with much less favorable opinions of these policies.

  • Specialist physicians and those with industry contacts have less favorable views of step therapy policies.

Increasing prescription drug costs impose economic burdens on patients and payers and contribute to substantial increases in insurance premiums for individuals and employers, as well as budget stresses for public programs.1,2 One widely used approach to control prescription costs is “step therapy,” which requires patients to try a less expensive—but clinically equivalent—drug for a given condition before a more expensive option can be approved.3 Authorization of the second-line agent may require attestation, often in the form of documentation in the medical chart or paperwork signed by the physician, that the patient took the initial medication and had adverse effects or inadequate clinical benefit.

Although studies have shown that step therapy can help reduce unnecessary use of expensive drugs, as well as patients’ out-of-pocket costs and overall health care spending,4-8 step therapy requirements have been criticized by some patient advocacy groups, citing the experiences of individual patients whose prescriptions were not covered due to these policies.9 Lobbying by patient and pharmaceutical industry groups has led several state legislatures to pass laws limiting the ability of health insurers to require step therapy.

In recent years, the U.S. Food and Drug Administration has approved growing numbers of medications, nearly all of which are sold at high prices whether or not they are better than currently available options.1 Step therapy may therefore grow in prominence among insurers seeking to rein in pharmaceutical spending.10 Since implementation of step therapy requires action by prescribing physicians, how physicians view step therapy policies, and whether such opinions differ across physician characteristics, will affect the eventual effect of step therapy and will indirectly affect the way that patients perceive these measures. We conducted a survey of a national sample of practicing physicians to explore these opinions.

Survey Administration

The American Board of Internal Medicine (ABIM) maintains a list of diplomates with active certification and maintenance of certification.11 The dataset includes physician demographics, medical training, and responses to the ABIM’s Practice Characteristics Survey, which we used to compare respondents and nonrespondents. The project was part of a larger survey on physician prescribing practices and was focused primarily on a new medication used to treat elevated lipid levels. In keeping with this clinical focus, the study sample included 500 internists and 1,000 specialists (500 endocrinologists and 500 cardiologists) randomly selected by the ABIM. To qualify for randomization, physicians must have previously reported being clinically active (i.e., ≥ 40% of their time and ≥ 21 hours per month in patient care activities) in nonacute settings (i.e., ≤ 50% of their time in the intensive care unit, emergency department, or cardiac catheterization lab). The project was approved by the Committee for the Protection of Human Subjects at Dartmouth College.12,13

The survey was conducted from May to December 2017. Contact was made via 2 postcards and 4 emails originating from ABIM, indicating that they had been randomly selected for a study to investigate how physicians make prescribing decisions. Questions regarding step therapy accounted for a subsection of the survey. These communications included the sponsoring institutions and lead investigators, a link to the online survey, an opportunity to opt out, and an offer of $50 upon completion. Nonresponders received a mailed version along with a $5 bill and an offer of $45 upon completion. Through this process, we learned that 84 of the 1,500 physicians in our cohort did not have current contact information.

Survey Development

Ten novel questions were developed by 3 of the study authors (MAF, ASK, and JA) to assess physician opinions of step therapy, all implemented as 5-point Likert scales ranging from either “strongly agree” to “strongly disagree” or “always” to “never,” depending on the question. The first question asked whether step therapy requirements could help keep medications affordable for patients and was followed by items asking whether the requirements were typically based on reasonable clinical evidence and implemented appropriately and efficiently. The next question asked physicians whether, setting cost aside, step therapy guidelines are useful in improving the clinical appropriateness of medication use. Five questions assessed elements of step therapy operation in practice settings, including whether the information system accounts for patients’ previous medication use, history of drug intolerance, adverse effects, or previous lack of clinical benefit with a given medication; whether the apparent clinical logic of the step therapy requirement was poor; and whether inflexibility and long delay times were commonly experienced. The final question asked whether physicians supported the enactment of laws to prohibit the use of step therapy. The full text of all 10 questions can be found in the Appendix (available in online article). We asked physicians for demographic information, years in practice, and specialty. Several survey items asked physicians to describe their interactions with the pharmaceutical industry, including receipt of gifts such as pens or free meals, use of drug samples, participation in programs such as consulting or advisory boards, and receipt of payment for travel costs or meetings.12

Statistical Analysis

For clarity of presentation we collapsed the survey response outcomes to 3 categories, combining somewhat/strongly agree and somewhat/strongly disagree, as well as often/always and rarely/never (5 category responses were retained for presentation in the Appendix). We assessed the rates at which physicians had favorable or unfavorable opinions of step therapy policy in relation to their demographic characteristics and extent of interaction with industry. We used chi-square tests to assess the statistical significance of observed associations. For the first 4 questions that focused on overall perceptions of step therapy, we developed ordinal logistic regression models to identify which physician characteristics were most strongly associated with favorable opinions of step therapy.

Of the 1,416 physicians in the sample, 686 responded (101 hard copy and 585 online) for a response rate of 48%. Table 1 shows the characteristics of the 686 physicians responding to the survey. There were 385 male respondents (56%), and self-reported race/ethnicity indicated that 54% were white, 32% Asian, 3% African American, 4% Hispanic, and 3% other. Among respondents, 195 (28%) practiced primary care internal medicine, 233 (34%) endocrinology, 182 (27%) cardiology, and 76 (11%) other specialties (reflecting survey responses about current practice areas, which may differ from ABIM records). Physicians were aged, on average, 44 years (standard deviation [SD] ± 8), 18 years (SD ± 8) after medical school graduation, and 13 years (SD ± 8) after completion of their residency. Interactions with industry were reported by 70% of respondents, including 57% who had received food or other gifts; 53% who used medication samples; 10% with consulting, advisory, or other paid roles; and 15% who had been reimbursed for travel or meeting costs. Among the non-respondents, 28% were internists, 39% cardiologists, and 33% endocrinologists; 60% were male.

Table

TABLE 1 Survey Respondent Characteristics (N = 686)

TABLE 1 Survey Respondent Characteristics (N = 686)

Characteristics Responses, n (%)
Gender
  Male 385 (56)
  Female 273 (40)
  Missing 28 (4)
Race
  Black 18 (3)
  Hispanic 28 (4)
  Asian 223 (32)
  White 368 (54)
  Other 24 (3)
  Missing 25 (4)
Age, years
  < 40 215 (31)
  40-54 341 (50)
  55+ 94 (14)
  Missing 36 (5)
Years since residency
  < 10 244 (36)
  10-20 266 (39)
  > 20 139 (20)
  Missing 37 (5)
Practice area
  Primary care 195 (28)
  Cardiology 182 (27)
  Endocrinology 233 (34)
  Other 76 (11)
Items received from industry
  No to all 184 (27)
  Yes to any of items below 484 (70)
  Missing 18 (3)
  Yes to any of 393 (57)
    Food or beverage in workplace
    Meal outside of campus/hospital
    Pens, notepads
    Tickets
  Yes to free drug samples 365 (53)
  Yes to any of 66 (10)
    Honoraria
    Consulting
    Advisory board
  Yes to any of 102 (15)
    Travel costs
    Meetings

Table 2 summarizes the responses to the 10 questions about step therapy (responses with the full 5-item scales are presented in the Appendix). For the initial questions about step therapy requirements, a majority of respondents viewed them as helping to keep medications affordable for patients (55% somewhat/strongly agree vs. 26% somewhat/strongly disagree, 19% neither agree/disagree); based on reasonable evidence (44% somewhat/strongly agree vs. 39% somewhat/strongly disagree, 17% neither agree/disagree); and improving medication appropriateness (59% somewhat/strongly agree vs. 19% somewhat/strongly disagree, 22% neither agree/disagree). Most respondents, however, had negative views of whether implementation of step therapy by payers was appropriate and efficient (59% somewhat/strongly disagree vs. 23% somewhat/strongly agree; 18% neither agree/disagree).

Table

TABLE 2 Overall Survey Responses to Questions About Step Therapy

TABLE 2 Overall Survey Responses to Questions About Step Therapy

Strongly/Somewhat Disagree (%) Neither Agree nor Disagree (%) Somewhat/Strongly Agree (%)
Step therapy requirements can help keep medications affordable for patients. 26 19 55
Step therapy requirements are generally based on reasonable clinical evidence. 39 17 44
Step therapy requirements are usually implemented appropriately and efficiently by payers. 59 18 23
Cost aside, step therapy guidelines are useful in improving the clinical appropriateness of medication use. 19 22 59
Never/Rarely (%) Sometimes (%) Often/Always (%)
The information system does not take into account a patient’s prior medication use history. 18 39 43
The information system does not take into account a history of drug intolerance, adverse effects, or lack of clinical benefit. 18 35 46
There is poor underlying clinical logic for the recommended choice. 22 41 37
There is inflexibility in the administration of step therapy rules and exceptions. 8 31 60
There are long delay times in processing decisions or exemptions. 9 32 59
Strongly/Somewhat Disagree (%) Neither Agree nor Disagree (%) Somewhat/Strongly Agree (%)
My state should pass a law that would prohibit the implementation of step therapy requirements. 12 23 65

Note: Row percentages may not add to 100% due to rounding.

The next 5 questions about the practical elements of using step therapy showed consistently negative opinions of the practice among physicians, including belief that information systems fail to consider previous medication use (43% often/always vs. 18% never/rarely) and fail to account for intolerance, adverse effects, or lack of benefit (46% often/always vs. 18% never/rarely). Most physicians also responded that the recommended choices had poor underlying logic (37% often/always vs. 22% never/rarely); that the programs’ administration was inflexible (60% often/always vs. 8% never/rarely); and that processing times were long (59% often/always vs. 9% never/rarely).

A majority of the physicians responding to the survey agreed with the concept of state legislation to prohibit step therapy (65% somewhat/strongly agree vs. 12% somewhat/strongly disagree).

Table 3 presents the variability in responses to the 4 initial questions about step therapy across different physician characteristics (cross-tabulations for all 10 questions about step therapy are provided in the Appendix). Specialist physicians and physicians who had interactions with industry were statistically significantly more likely to hold negative views about whether step therapy could help patients afford their medications and whether step therapy policies could improve the appropriateness of medication use. All physician groups held negative views of the efficiency with which step therapy was implemented, with negative views slightly more common among specialists and those who had interactions with industry. Physician age, race, sex, and years since completing residency were not associated with their opinions of step therapy.

Table

TABLE 3 Survey Responses by Physician Characteristics

TABLE 3 Survey Responses by Physician Characteristics

Independent Variablea Step therapy requirements can help keep medications affordable for patients (%) Step therapy requirements are generally based on reasonable clinical evidence (%) Step therapy requirements are usually implemented appropriately and efficiently by payers (%) Cost aside, step therapy guidelines are useful in improving the clinical appropriateness of medication use (%)
Disagree Neither Agree P Value Disagree Neither Agree P Value Disagree Neither Agree P Value Disagree Neither Agree P Value
Specialist
  Internists 19 19 62 < 0.01 26 17 57 < 0.001 53 21 26 < 0.01 11 20 69 < 0.001
  Cardiologist 21 20 59 34 18 48 53 19 28 17 18 65
  Endocrinologist 38 16 46 55 14 31 69 13 18 29 29 41
  Other specialist 23 26 52 31 24 45 52 27 21 12 16 72
Age, years
  < 40 29 20 52 0.34 39 17 43 0.94 57 22 21 0.18 16 25 59 0.07
  40-54 23 19 57 38 16 46 57 17 25 18 22 60
  ≥ 55 32 15 53 39 19 42 66 12 22 30 17 53
From resident years
  < 10 27 19 54 0.36 38 19 44 0.84 55 23 23 0.09 14 24 62 0.20
  10-20 24 21 55 40 15 45 58 16 26 20 22 58
  > 20 29 13 58 38 17 45 66 15 19 25 22 53
Any benefit (gift, payment, reimburse)
  Yes 31 17 52 < 0.01 43 16 42 < 0.01 62 16 21 0.01 23 23 54 < 0.01
  No 15 24 61 29 20 52 49 23 28 8 20 72

Note: Row percentages may not add to 100% due to rounding.

aCategories of outcome variables: disagree (strongly/somewhat disagree), neither (neither agree nor disagree), agree (somewhat/strongly agree).

Table 4 summarizes the results of the ordinal regression models that showed that endocrinologists were less likely to have positive opinions of step therapy compared with general internists, and physicians with interactions with industry were less likely to have positive opinions of step therapy compared with those without interactions.

Table

TABLE 4 Predictors of Responses to Questions About Step Therapy

TABLE 4 Predictors of Responses to Questions About Step Therapy

Independent Variable Step therapy requirements can help keep medications affordable for patientsa Step therapy requirements are generally based on reasonable clinical evidencea Step therapy requirements are usually implemented appropriately and efficiently by payersa Cost aside, step therapy guidelines are useful in improving the clinical appropriateness of medication usea
ORb 95% CI P Value ORb 95% CI P Value ORb 95% CI P Value ORb 95% CI P Value
Specialist
  Internists ref
  Cardiologist 0.97 0.64 1.49 0.1 0.73 0.49 1.10 0.5 1.18 0.78 1.77 0.1 0.92 0.58 1.47 0.5
  Endocrinologist 0.53 0.35 0.78 0.002 0.34 0.23 0.51 < 0.0001 0.62 0.42 0.94 0.003 0.37 0.24 0.57 < 0.0001
  Other specialist 0.75 0.40 1.38 0.8 0.78 0.42 1.42 0.5 1.07 0.58 1.97 0.6 1.39 0.66 2.94 0.053
Age, years
  < 40 ref
  40-54 1.25 0.72 2.18 0.1 1.00 0.58 1.73 0.7 1.48 0.85 2.58 0.4 1.46 0.76 2.78 0.09
  ≥ 55 0.77 0.33 1.78 0.3 0.83 0.37 1.89 0.6 1.54 0.66 3.62 0.5 0.95 0.38 2.35 0.5
From resident years
  < 10 ref
  10-20 0.98 0.57 1.70 0.5 1.10 0.64 1.87 1.0 0.77 0.45 1.33 0.6 0.69 0.36 1.31 0.5
  > 20 1.26 0.60 2.66 0.4 1.18 0.58 2.41 0.7 0.48 0.23 1.01 0.054 0.63 0.28 1.42 0.4
Any benefit (gift, payment, reimburse)
  No ref
  Yes 0.66 0.46 0.95 0.02 0.73 0.51 1.03 0.07 0.71 0.50 1.02 0.06 0.55 0.36 0.84 0.006

aCategories of outcome variables: 1. somewhat/strongly agree, 2. neither agree/nor disagree, 3. strongly/somewhat disagree.

bThe OR is based on the likelihood of “somewhat/strongly agree.”

CI = confidence interval; OR = odds ratio; ref = reference.

In a national survey of primary care and physicians from 2 specialties, we found that, while a majority agreed with the principles underlying step therapy as an approach to formulary management, most responding physicians had negative opinions about how the policies are implemented, and most respondents favored legislation banning the approach. Physicians in medical subspecialties, especially endocrinology, and those with ties to the pharmaceutical industry were more likely to hold negative views of step therapy, compared with general internists and physicians without industry relationships. Our results have important implications for the design of policy interventions to improve the quality and cost-effectiveness of physician prescribing.

Physicians navigating the step therapy process require information about the formulary assignments for multiple medications across multiple insurers. Ideally, these elements will be provided by electronic health records (EHR) during the process of writing prescriptions,14 but many EHRs do not have such capabilities.15 These limitations mean that obtaining approval for medications with a step therapy requirement creates additional work for physicians. Front-line clinicians already struggle with a range of burdensome administrative requirements, and many EHRs add complexity to physicians’ work processes.16 In this situation, it is not surprising that many physicians have negative opinions about the fairness, efficiency, and timeliness of step therapy processes.

More encouraging is the finding that most physicians continue to agree that step therapy has the potential to improve the quality of medication use and to make medications more affordable for patients. This suggests that there may yet be an opportunity for physicians to develop more generally favorable views of step therapy if the approach can be implemented more effectively. Increased transparency of formulary policies for public and private insurers may prevent some of the confusion faced by prescribers when trying to identify which medications require step therapy before approval. Integration of this formulary information into EHRs in a manner that fits into clinical workflows would allow prescribers to address step therapy requirements at the moment of medication selection and to discuss them with patients. Implementation of these and other changes, coupled with rigorous evaluation of their effects, could not only increase the efficiency of prescribing but could change the negative opinions that many physicians hold about step therapy.

Physician opinions of step therapy differed across a subset of characteristics. In particular, primary care physicians were more likely to view step therapy favorably than subspecialists in endocrinology. One possible explanation for this difference is that endocrinologists may see more patients with complex presentations of a given condition, for whom first-line medications were not successful and who may more often require prescriptions restricted by step therapy policies; the persistent high costs of insulin and other diabetes medications may contribute to their experiences.17,18 It is also possible that primary care physicians, responsible for the entire range of a patient’s care, are more attuned to the cost barriers created by multiple expensive prescriptions and thus more sympathetic to the need for policies to manage medication costs. Primary care practices may have more support staff or office processes to help with any paperwork related to step therapy. In either event, increasing the transparency and efficiency of the step therapy process would likely improve perceptions for all groups of physicians.

Physicians interacting with industry were more likely to hold negative views of step therapy. Earlier work has raised a range of concerns about the effect of gifts to physicians on prescribing and other clinical decisions.19-21 Step therapy policies are largely reactions to the high prices charged for many medications in the United States. If physicians with more industry connections hold negative opinions of step therapy policies and resist using the less expensive medications recommended, this may represent a successful outcome of marketing expenditures by industry. Recognizing this additional effect of physician interactions with manufacturers may inform current debates about how to manage such relationships and conflict of interest policies more generally.

Limitations

Limitations of the data collected in the survey may affect the interpretation of this study’s results. A prespecified subset of specialties was included in the survey, so the findings do not necessarily reflect the views of all physicians, although the specialties sampled write large volumes of outpatient prescriptions. We could not be certain whether nonresponding physicians had different frequencies of industry interactions or certain views on step therapy. Several varieties of step therapy policies exist, differing in complexity, ease of approval, and other elements.3-8 Physicians’ responses may have been shaped by whichever type of policy they had encountered most recently before completing the survey, by the predominant insurance providers in their region, or by the policies encountered most often, but space constraints of the survey did not allow for the inclusion of these questions.

The step therapy questions were embedded in a larger survey about prescribing decisions and responding to these other questions may have influenced responses to the step therapy questions. The questions on step therapy had not been previously validated, which may have limited their generalizability. While we identified associations between survey responses, we cannot draw firm conclusions about causality. For example, our finding that physicians with industry interactions held more negative views of step therapy may reflect underlying attitudes in those physicians that drive their decisions to accept industry gifts and also their opinions of step therapy.

A majority of physicians recognize the potential of step therapy to address problems with the quality and costliness of prescription drug therapy, but many hold negative views of how these policies are implemented. Insurers, EHR vendors, and others working to improve medication use must improve the transparency and efficiency with which step therapy is implemented to ensure the acceptability of this important cost containment approach.

ACKNOWLEDGMENTS

The authors thank Steven Woloshin, MD, MS, and Lisa M. Schwartz, MD, MS, at the Center for Medicine and the Media, Dartmouth Institute for Health Policy and Clinical Practice, for their work on survey design, institutional review board approval, and implementation. The authors also thank Doris Peter, PhD, Yale School of Medicine, for her help in implementing the study.

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Table

Table

Strongly Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Strongly Agree P Value
Step therapy requirements can help keep medications affordable for patients.
Specialist
   Internists 8 (4) 28 (15) 37 (19) 85 (44) 34 (18) < 0.0001
   Cardiologist 17 (10) 20 (11) 35 (20) 86 (48) 20 (11)
   Endocrinologist 35 (15) 53 (23) 37 (16) 84 (36) 22 (10)
   Other specialist 9 (15) 5 (8) 16 (26) 21 (34) 11 (18)
Age, years
   < 40 21 (10) 40 (19) 42 (20) 85 (40) 25 (12) 0.6
   40-54 31 (9) 47 (14) 65 (19) 146 (44) 46 (14)
   ≥ 55 14 (15) 16 (17) 14 (15) 35 (38) 14 (15)
From resident years
   < 10 23 (10) 43 (18) 45 (19) 100 (41) 31 (13) 0.6
   10-20 23 (9) 40 (15) 56 (21) 109 (41) 35 (13)
   > 20 19 (14) 20 (15) 18 (13) 60 (44) 19 (14)
Any benefit (gift, payment, reimburse)
   Yes 56 (12) 91 (19) 82 (17) 200 (42) 51 (11) 0.0001
   No 13 (7) 15 (8) 43 (24) 75 (41) 36 (20)
Step therapy requirements are generally based on reasonable clinical evidence.
Specialist
   Internists 19 (10) 31 (16) 32 (17) 82 (43) 27 (14) < 0.0001
   Cardiologist 22 (12) 39 (22) 32 (18) 67 (37) 19 (11)
   Endocrinologist 54 (23) 74 (32) 33 (14) 53 (23) 18 (8)
   Other Specialist 5 (8) 14 (23) 15 (24) 22 (35) 6 (10)
Age, year
   < 40 26 (12) 58 (27) 37 (17) 71 (33) 21 (10) 0.6
   40-55 52 (15) 77 (23) 53 (16) 118 (35) 37 (11)
   ≥ 56 19 (21) 17 (18) 17 (18) 28 (30) 11 (12)
From resident years
   < 10 25 (10) 66 (27) 45 (19) 82 (34) 24 (10) 0.2
   11-20 45 (17) 61 (23) 39 (15) 92 (35) 28 (11)
   > 20 26 (19) 25 (19) 23 (17) 44 (33) 17 (13)
Any benefit (gift, payment, reimburse)
   Yes 82 (17) 123 (26) 76 (16) 155 (32) 45 (9) 0.02
   No 18 (10) 34 (19) 36 (20) 69 (38) 25 (14)
Step therapy requirements are usually implemented appropriately and efficiently by payers.
Specialist
   Internists 31 (16) 70 (37) 40 (21) 43 (23) 7 (4) 0.001
   Cardiologist 44 (25) 51 (29) 33 (19) 44 (25) 6 (3)
   Endocrinologist 79 (34) 80 (35) 31 (13) 34 (15) 7 (3)
   Other specialist 9 (15) 23 (37) 17 (27) 10 (16) 3 (5)
Age, years
   < 40 44 (21) 78 (37) 47 (22) 35 (16) 9 (4) 0.1
   40-56 83 (25) 109 (33) 58 (17) 75 (22) 10 (3)
   ≥ 57 32 (35) 29 (32) 11 (12) 17 (18) 3 (3)
From resident years
   < 10 43 (18) 89 (37) 55 (23) 43 (18) 12 (5) 0.01
   12-20 70 (27) 83 (32) 42 (16) 62 (24) 6 (2)
   > 20 44 (33) 45 (33) 20 (15) 22 (16) 4 (3)
Any benefit (gift, payment, reimburse)
   Yes 134 (28) 164 (34) 79 (16) 90 (19) 13 (3) 0.006
   No 29 (16) 60 (33) 41 (23) 41 (23) 10 (6)
Cost aside, step therapy guidelines are useful in improving the clinical appropriateness of medication use.
Specialist
   Internists 15 (9) 4 (2) 34 (20) 36 (21) 84 (49) < 0.0001
   Cardiologist 22 (14) 5 (3) 29 (18) 42 (26) 64 (40)
   Endocrinologist 52 (24) 12 (6) 64 (29) 32 (15) 57 (26)
   Other specialist 5 (9) 2 (3) 9 (16) 23 (40) 19 (33)
Age, years
   < 40 27 (14) 5 (3) 50 (25) 45 (23) 72 (36) 0.3
   40-57 44 (14) 12 (4) 66 (22) 67 (22) 115 (38)
   ≥ 58 22 (25) 4 (5) 15 (17) 14 (16) 32 (37)
From resident years
   < 10 27 (12) 5 (2) 53 (24) 53 (24) 84 (38) 0.5
   13-20 39 (16) 10 (4) 52 (22) 50 (21) 90 (37)
   > 20 26 (21) 5 (4) 28 (22) 23 (18) 44 (35)
Any benefit (gift, payment, reimburse)
   Yes 84 (19) 20 (4) 104 (23) 89 (20) 154 (34) 0.0003
   No 10 (6) 3 (2) 31 (20) 44 (28) 70 (44)
My state should pass a law that would prohibit the implementation of step therapy requirements.
Specialist
   Internists 25 (14) 3 (2) 53 (30) 54 (30) 44 (25) <0.0001
   Cardiologist 17 (10) 5 (3) 35 (22) 60 (37) 45 (28)
   Endocrinologist 8 (4) 4 (2) 36 (19) 69 (37) 68 (37)
   Other specialist 2 (4) 5 (9) 8 (14) 31 (55) 10 (18)
Age, years
   < 40 8 (4) 8 (4) 31 (16) 80 (42) 64 (34) 0.001
   40-58 33 (11) 5 (2) 69 (23) 111 (38) 76 (26)
   ≥ 59 10 (13) 3 (4) 25 (33) 17 (22) 21 (28)
From resident years
   < 10 9 (4) 7 (3) 41 (19) 91 (41) 73 (33) 0.0003
   14-20 25 (11) 7 (3) 47 (21) 88 (39) 57 (25)
   > 20 17 (15) 3 (3) 39 (34) 27 (23) 30 (26)
Any benefit (gift, payment, reimburse)
   Yes 30 (7) 10 (2) 87 (21) 144 (35) 141 (34) 0.0001
   No 22 (13) 7 (4) 44 (26) 70 (41) 26 (15)
    Never Rarely Sometimes Often Always P Value
The information system does not take into account a patient’s prior medication use history.
Specialist
   Internists 11 (6) 30 (16) 71 (37) 65 (34) 15 (8) 0.7
   Cardiologist 7 (4) 23 (13) 76 (42) 65 (36) 8 (4)
   Endocrinologist 10 (4) 34 (15) 83 (36) 90 (39) 16 (7)
   Other specialist 3 (5) 4 (6) 29 (47) 22 (35) 4 (6)
Age, years
   < 40 8 (4) 27 (13) 95 (44) 78 (36) 6 (3) 0.09
   40-59 17 (5) 49 (15) 125 (37) 116 (34) 30 (9)
   ≥ 60 4 (4) 12 (13) 29 (31) 41 (44) 7 (8)
From resident years
   < 10 10 (4) 30 (12) 109 (45) 82 (34) 11 (5) 0.2
   15-20 12 (5) 42 (16) 98 (37) 96 (36) 17 (6)
   > 20 7 (5) 18 (13) 42 (31) 55 (40) 14 (10)
Any benefit (gift, payment, reimburse)
   Yes 21 (4) 70 (14) 178 (37) 178 (37) 36 (7) 0.2
   No 10 (5) 21 (12) 80 (44) 64 (35) 7 (4)
The information system does not take into account a history of drug intolerance, adverse effects, or lack of clinical benefit.
Specialist
   Internists 11 (6) 26 (14) 60 (31) 84 (44) 10 (5) 0.9
   Cardiologist 7 (4) 26 (15) 68 (38) 70 (39) 8 (4)
   Endocrinologist 11 (5) 30 (13) 84 (36) 90 (39) 18 (8)
   Other specialist 3 (5) 7 (11) 23 (37) 25 (40) 4 (6)
Age, years
   < 40 6 (3) 30 (14) 87 (41) 80 (37) 11 (5) 0.1
   40-60 19 (6) 51 (15) 105 (31) 142 (42) 20 (6)
   ≥ 61 5 (5) 5 (5) 33 (36) 43 (47) 6 (7)
From resident years
   < 10 9 (4) 34 (14) 93 (38) 92 (38) 14 (6) 0.3
   16-20 14 (5) 42 (16) 83 (31) 115 (43) 11 (4)
   > 20 7 (5) 12 (9) 48 (36) 56 (41) 12 (9)
Any benefit (gift, payment, reimburse)
   Yes 19 (4) 62 (13) 167 (35) 201 (42) 33 (7) 0.2
   No 13 (7) 27 (15) 67 (37) 68 (37) 7 (4)
There is poor underlying clinical logic for the recommended choice.
Specialist
   Internists 6 (3) 41 (21) 89 (46) 51 (27) 5 (3) < 0.0001
   Cardiologist 4 (2) 40 (22) 80 (45) 49 (27) 6 (3)
   Endocrinologist 4 (2) 35 (15) 71 (30) 96 (41) 27 (12)
   Other specialist 4 (6) 11 (18) 35 (56) 10 (16) 2 (3)
Age, years
   < 40 3 (1) 46 (22) 99 (46) 54 (25) 12 (6) 0.3
   40-61 11 (3) 61 (18) 133 (39) 108 (32) 24 (7)
   ≥ 62 2 (2) 15 (16) 36 (39) 36 (39) 4 (4)
From resident years
   < 10 5 (2) 52 (21) 113 (47) 58 (24) 14 (6) 0.2
   17-20 6 (2) 48 (18) 102 (38) 90 (34) 19 (7)
   > 20 5 (4) 23 (17) 52 (38) 49 (36) 7 (5)
Any benefit (gift, payment, reimburse)
   Yes 9 (2) 83 (17) 190 (39) 165 (34) 36 (7) 0.0003
   No 9 (5) 44 (24) 84 (46) 41 (23) 4 (2)
There is inflexibility in the administration of step therapy rules and exceptions.
Specialist
   Internists 4 (2) 18 (9) 70 (36) 74 (39) 26 (14) 0.01
   Cardiologist 2 (1) 12 (7) 59 (33) 87 (49) 18 (10)
   Endocrinologist 3 (1) 9 (4) 57 (24) 122 (52) 42 (18)
   Other specialist 3 (5) 4 (6) 23 (37) 26 (42) 6 (10)
Age, years
   < 40 1 (0) 18 (8) 76 (36) 99 (46) 20 (9) 0.03
   40-62 6 (2) 21 (6) 99 (29) 158 (47) 52 (15)
   ≥ 63 3 (3) 1 (1) 27 (29) 43 (46) 19 (20)
From resident years
   < 10 3 (1) 21 (9) 83 (34) 110 (46) 24 (10) 0.2
   18-20 3 (1) 17 (6) 82 (31) 121 (46) 42 (16)
   > 20 4 (3) 5 (4) 36 (26) 68 (50) 23 (17)
Any benefit (gift, payment, reimburse)
   Yes 7 (1) 25 (5) 142 (29) 237 (49) 71 (15) 0.02
   No 5 (3) 18 (10) 67 (37) 71 (39) 21 (12)
There are long delay times in processing decisions or exemptions.
Specialist
   Internists 5 (3) 15 (8) 74 (39) 72 (38) 25 (13) 0.2
   Cardiologist 2 (1) 12 (7) 56 (31) 80 (45) 29 (16)
   Endocrinologist 4 (2) 15 (6) 62 (27) 99 (42) 53 (23)
   Other specialist 3 (5) 5 (8) 19 (31) 25 (40) 10 (16)
Age, years
   < 40 1 (0) 14 (7) 81 (38) 85 (40) 32 (15) 0.03
   40-63 7 (2) 27 (8) 103 (31) 132 (39) 68 (20)
   ≥ 64 4 (4) 3 (3) 23 (25) 48 (52) 15 (16)
From resident years
   < 10 4 (2) 11 (5) 95 (39) 98 (41) 33 (14) 0.002
   19-20 3 (1) 27 (10) 76 (29) 101 (38) 58 (22)
   > 20 5 (4) 9 (7) 34 (25) 68 (50) 20 (15)
Any benefit (gift, payment, reimburse)
   Yes 7 (1) 29 (6) 146 (30) 212 (44) 88 (18) 0.03
   No 7 (4) 18 (10) 65 (36) 63 (35) 29 (16)

Note: Row percentages may not add to 100% due to rounding.

aN (%) of responses for the questions about step therapy by characteristics.

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