Every DermPA^TM has a story about barriers to effective treatment. 

Take the woman with hidradenitis suppurativa. She struggles with painful nodules and scarring. Her dermatology PA recommends a biologic that could finally provide relief, but her insurer requires her to “fail” topical antibiotics and systemic tetracyclines for months, despite a history of nonresponse. Her condition worsens, leading to missed work, emergency visits, more scarring, and escalating pain. 

Or consider the teenage boy with severe acne. His PA prescribes isotretinoin, a proven and effective option. Yet, before he can begin, the pharmacy benefit manager demands not one, but two prior authorizations—including mandatory step therapy. His acne worsens, and so does his mental health, while he waits for access to a medication that has been available for decades. 

Then there’s the man with psoriasis, stable for years on a biologic with excellent control. Midyear, his employer switches insurance plans. The new plan doesn’t cover the medication he depends on and insists on switching him to an alternative. His psoriasis flares. To reinstate his prior treatment, he faces weeks of paperwork, calls, and appeals—during which his symptoms return and his quality of life deteriorates. 

These stories are common, and the bureaucratic processes causing these delays are harming patients. At the center is utilization management—insurance practices such as prior authorization and step therapy. Originally intended to control costs, these policies are now often applied in ways that restrict access, delay care, and undermine clinical judgment. 

In theory, utilization management promotes evidence-based care and lower-cost options first. In practice, it forces patients to fail cheaper medications despite proven success on others, and it clogs the system with paperwork that delays care. For PAs, the result is hours of administrative burden—time taken away from patients. 

This isn’t just a clinical issue—it’s an economic one. Administrative costs make up 15% to 30% of U.S. health spending. A significant portion comes from prior authorizations, step therapy appeals, and other insurer requirements. Dermatology practices must dedicate staff to chasing approvals, delaying reimbursements, and diverting resources from patient care. These costs ripple across the system without improving outcomes. 

Reform is possible. States are beginning to act. Illinois passed the Healthcare Protection Act, banning step therapy and prior authorization for inpatient mental health care. New York empowered providers to override step therapy when a drug is expected to be ineffective or harmful. Colorado, Arkansas, and Minnesota have also enacted laws limiting “fail first” requirements and streamlining appeals. 

At the federal level, the Safe Step Act—led by a bipartisan group in Congress—would create a clear framework for exceptions to step therapy protocols. The bill is a chance to ensure patients nationwide get timely, appropriate care without unnecessary insurer roadblocks. 

What You Can Do 

Contact your members of Congress today and urge them to support the Safe Step Act. Patients deserve timely, effective treatment, not endless paperwork and denials. 

The downstream cost of untreated or undertreated disease is too high: worsening symptoms, lost productivity, hospitalizations, and lasting harm. We didn’t go into dermatology to battle red tape. With the Safe Step Act, we can take a real step toward fixing this system and get back to what we do best—helping people feel better, inside and out.