When you’re injured or sick, who do you think should decide what prescription medication will help you feel better, your doctor or your health insurance company? I’m betting just about everyone reading this said the doctor. Well, I am a doctor and I can tell you that all too often, the choice is made by the insurance company, no matter what you or your doctor wants. And it’s not a question of what medication is best for your situation, it’s a question of what’s cheapest for the insurer.
This practice is sometimes called “fail first” because the insurer will require you to try one or more medications that fail to help you before they’ll allow you to get the one the doctor prescribed. It’s also known as “step therapy” because the insurer wants to see you go through multiple steps with various cheaper treatments before you can have the original prescription.
As a physician, I find myself extremely frustrated when a decision I’ve made after personal consultation with the patient and careful consideration of his or her needs is second-guessed by someone at the health insurance company. There’s the frustration that my staff and I spend so much time jumping through hoops, trying to get prescriptions approved. That time has a financial cost attached and therefore drives up the cost of caring for patients. It’s also frustrating to watch patients suffer needlessly as one medication after another fails them. Finally, I’m frustrated that patient safety is being compromised in the name of cost containment.
I specialize in pain management, but prescription pain medications are not the only ones insurers are subjecting to step therapy. Treatments for arthritis, diabetes, multiple sclerosis, and even cancer are being denied in favor of a cheaper therapy on which the patient must “fail first.” Think about what that means to a cancer patient. A failed treatment is one that allows the cancer to progress. The same is true of other serious illnesses. There’s a lot of talk in medicine now about patient centered healthcare, and this is not a situation in which the patient comes first.
Fortunately, Ohio legislators have the opportunity to do something. State Senators Peggy Lehner (R-Kettering) and Charleta Tavares (D-Columbus) have introduced Senate Bill 243 which would place some controls on the use of step therapy in Ohio. The bill would require guidelines for when an insurer can insist on a substitute medication, guidelines developed by medical professionals. The decision couldn’t be based on cost alone. The bill would spell out some conditions under which the patient should get the prescribed medication right away, such as cases in which he or she is already doing well on a medication the doctor wants to continue.
The bill would also require insurers to have a clear, easier process by which doctors and patients could appeal step therapy decisions.
Step therapy is increasingly being used by insurers in an attempt to control costs, but in the process it subverts the physician’s judgement and discretion and places patients at more risk than is absolutely necessary. I urge readers to support upcoming legislation that gives patients better standing when step therapy requirements are imposed.