Background/Purpose: Early diagnosis and treatment of rheumatoid arthritis (RA) is crucial in minimizing disease damage. Step-therapy, a form of prior authorization used by payers to manage costs, determines which medications will be covered and thus affordable. Expansion of the Institute for Healthcare Improvements Triple Aim initiative to the Quadruple Aim initiative added the aim to promote workplace happiness for providers. We examined provider beliefs regarding the role of step-therapy in managing health care costs, quality of care delivered, and on clinical autonomy and job satisfaction in North Carolina. We also evaluated provider awareness and agreement with proposed state policies aimed at streamlining step-therapy exceptions processes.

Methods: In this cross-sectional survey study, a web-based questionnaire was emailed on March 7 and March 16, 2017 to all members of the North Carolina Rheumatology Association. We summarized the data through frequency counts to determine knowledge, beliefs and perception of step-therapy, and chi-square tests were used to compare respondent knowledge of state legislation, NC HB 1048, to their beliefs about autonomy and job satisfaction.

Results: The survey was sent to 118 providers, and the final analysis included 38 completed surveys (effective response rate of 32.2%). Respondents were more likely to be male (58%), report 20+ years in practice (53%), work in a private practice (87%), and see patients with Medicare (34%) or private insurance (38%). Providers disagreed that step-therapy reduced costs for society overall (52%) or patients (57%). Instead, 82% agreed that step-therapy reduced costs for insurance companies. With respect to quality, 92% of providers believed step-therapy negatively impacted the quality of care provided to patients (50% somewhat reduced quality, 42% greatly reduced quality) and 82% of providers agreed that step-therapy delayed beginning proper treatment (50% agree, 31% strongly agree). Nearly 90% of providers reported step-therapy negatively affects their autonomy and 87% reported step-therapy negatively impacting their job satisfaction. When considering the burden of step-therapy on providers, 79% of providers reported step-therapy as being common when prescribing for RA. Most respondents (76%) were directly involved in processing step-therapy paperwork. In addition, half of respondents reported spending >60 minutes on step-therapy paperwork in an average clinic day. Despite the burden of step-therapy, only 47% of providers were aware of proposed NC state legislation to reduce the burden of step-therapy. Notably nearly all surveyed providers agreed with the exceptions proposed within the state legislation.

Conclusion: Providers view step-therapy as a burden without justifiable results for cost and quality. This unjustified burden coupled with provider agreement with state proposed legislation suggests that providers should engage with policy makers to support legislative action on this topic. Additionally, provider groups such as the ACR should create advocacy groups to increase awareness of state and federal legislation.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/impact-of-step-therapy-protocols-on-north-carolina-rheumatologists-job-satisfaction-and-the-quality-of-care-received-by-their-patients-with-rheumatoid-arthritis/