A Dangerous Combination: CVD and Policies built to Protect Insurance Companies First

by | Apr 10, 2025 | Blog

The National Hispanic Council on Aging wishes to remind our community and constituents of the strenuous and deadly relationship between chronic illnesses like CVD and the lengthy process it takes for patients to get the medications they need. Policies like Step Therapy (ST) and Prior Authorization (PA) are dense roadblocks between patients and their medications, which result in a very long and arduous process at the expense of the patient’s health. In the United States, the primary cause of death remains to be heart diseases, chronic cardiovascular illnesses that when left untreated can result in deadly heart attacks and strokes.

The Dangers of CVD

To review, heart disease is the primary cause of death for Americans. In 2022, 702,880 Americans died from heart disease, and it’s estimated that someone in the United States dies of heart disease every 33 seconds. These are truly devastating statistics that might seem insurmountable, but there are ways we can work to decrease these numbers.

For a more in-depth review, check out our previous blog posts:

Solving the prevalence of poor heart health in the US is a complex task, the investigation of which will lead you to a mess of overlapping socioeconomic, cultural, and political circumstances. However, there are direct ways we can change that death rate, and lessen the toll on patients’ health, and the answers lie in the review of several key policies at work in our healthcare system.

Step Therapy (ST) & Prior Authorization (PA)

You may have heard of these policies before, and have likely even experienced them firsthand. ST and PA are policies used by insurance companies to control costs and manage the use of prescription drugs.

Step Therapy is a burden placed directly onto a patient’s treatment plan. While a doctor may prescribe a medication that will assuredly help manage a patient’s condition, the patient’s insurance will often deny it because there are cheaper drugs used to treat the same condition. These cheaper medications could have side-effects or simply be less effective, but the patient’s insurance requires them to rule it out as an option before they approve the more effective and expensive medication. Depending on how long the insurance deems is necessary for the patient to try the cheaper medication, patients can experience varying levels of physical discomfort and worsened conditions and illness, before the medication they need is finally approved.

Prior Authorization works in the same capacity for insurance companies to control cost, but acts as a roadblock for physicians. A patient’s insurance may require their doctor to receive pre-approval for the medications, treatments, or tests that they intend to prescribe for the patient’s care. PA is frequently used even for medical equipment that the patient may require.

So How are ST & PA Part of the Problem?

Some may be inclined to give these policies the benefit of the doubt, arguing in favor of frugality, or that the cheaper medication may be good enough. But this cost-effectiveness is coming at the risk of patients’ health, and in many cases even their lives. While a patient is taking the time to try a cheaper, less effective medication, they may be risking severe complications, and all simply to prove to their insurance that they need what their doctor recommended.

According to a survey conducted by the American Medical Association (AMA), more than 1 in 4 physicians (29%) report that prior authorization has led to a serious adverse event for a patient in care. Additionally, 23% report that PA has led to a patient’s hospitalization, 18% report that it has led to “a life-threatening event or required intervention to prevent permanent impairment or damage,” and 8% report that it has led to a patient’s “disability/permanent bodily damage, congenital anomaly/birth defect or death.”

The AMA also found that about 1 in 3 physicians report that the criteria these insurance companies base their approval on is “rarely or never evidence-based,” suggesting that the criteria in those cases isn’t considering the patient’s livelihood a priority.

The same survey found that 77% of physicians reported the initial treatments required by step therapy to be ineffective. 80% reported that the PA process sometimes results in a patient paying for their medication out-of-pocket, and 82% report that it can lead to patient’s complete abandonment of their treatment.

These statistics do not represent any one illness specifically, but we have to consider the levels of severity that come with such deadly illnesses as cardiovascular diseases. Patients with heart disease, or other cardiovascular diseases, are risking devastating consequences in trying to meet the requirements set by their insurance. In the time it takes to receive approval for the medication recommended by their doctor, they risk heart attacks and strokes, which each hold the possibility of permanent disability or death.

These statistics speak for themselves. Policies like ST & PA are active contributors to Americans’ poor health and mortality, and have prioritized the cost of medications over the livelihood of countless patients.

The National Hispanic Council on Aging believes that we can review these policies, and with the help of experts, lawmakers, and community leaders, create actionable solutions to recommend to legislators for the betterment of health across the United States.

References: