As a doctor, I am forced by insurance-company requirements to let many of my patients fail on older, ineffective medicines before they become eligible for the treatments I know will make them better.
DOZENS of times a year I prescribe medicine to my patients that I know won’t help them. I watch and do nothing as their symptoms get worse and they spend dollar after dollar on useless treatments.
This is not my choice.
I am forced to do this by insurance companies that require many of my patients to fail on older, ineffective medicines before they become eligible for the treatments I know will make them better.
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This is a process called step therapy or, more accurately, fail first. As in, my patients must fail first on older, cheaper drugs before insurance companies determine they have earned the right to take modern, effective medicine.
Insurance companies say fail-first policies keep costs down because older drugs are often less expensive than the latest medicine. They reason that patients could get lucky on an older drug and therefore not need a newer, more expensive one. That’s the theory anyway.
The reality is that fail-first policies are an unprecedented cost-shifting scheme away from insurers and onto the backs of my patients. Because patients must fail on two, three, sometimes four rounds of treatment, their out-of-pocket expenses skyrocket as they shell out for copays on rounds and rounds of doctor visits and drugs that do nothing for them.
Fail-first protocols are not based on the physician’s assessment of the best treatment option for the patient’s condition. Instead, these are one-size-fits-all tools health plans enforce. Ultimately, they create unnecessary obstacles for patients, increase the administrative burden on medical staff, and undermine the decision made between patients and physicians. As a result, these protocols can lead to delays in access to medications that offer the greatest potential medical benefit, often leading to disease progression. For many living with rheumatic and autoimmune conditions, fail-first practices can also create potentially life-threatening outcomes.
It is a heartbreaking and dangerous process.
Last year, a woman under my care with rheumatoid arthritis, a chronic disorder that causes the immune system to attack a patient’s joints, had to wait six months before getting the treatment that was right for her. During the six months, she was made to take a first-line treatment that I knew would fail. This was followed by two other treatments that were essentially the exact same medicine, only to fail both as expected. Finally, her insurer allowed her to be placed on the treatment I originally prescribed.
That’s six months of suffering through extreme pain, loss of movement and loss of independence. All the while her family was burdened by the costs of ineffective drugs, office visits, special braces and time off work.
My patients and I share two goals: develop the most effective treatment plans for their illness so they get better as quickly as possible and don’t go broke in the process. Fail first puts both these goals out of reach, enriching insurance companies while my patients stay sick longer and pay more than they should.
The state Legislature is currently looking at ways to address high out-of-pocket costs for consumers. It is my hope our representatives will also address policies like fail first and the impact these types of restrictions have on patient care. I support an end to fail first in Washington state so my patient’s health is managed by my clinical judgment and not by a health-plan bureaucrat or computer algorithm.