In the News
News-Press: Health, not cost should drive patient care
Insurance companies are increasingly overruling doctors and requiring patients take cheaper, less suitable medications before they are allowed to fill their doctor’s prescription. I know firsthand that forcing patients to take different drugs than those prescribed can delay effective treatment and have unintended consequences. As lawmakers work out how they want to overhaul the nation’s healthcare, they should consider limiting the ability of insurance companies to veto the treatment decisions of patients and their doctors.
I suffer from severe asthma, but my doctor thought it could be effectively controlled by prescribing Advair. [S/he] was right. For five years, I had no issues with my asthma. Then, without notice, my insurance company denied my prescription and forced me to switch to a cheaper, substitute drug. After a month on the new medication, my asthma was out of control and I was having regular heart palpitations, which required additional visits to my doctor. My insurer padded its profits, but switching medications substantially reduced my health and well-being.
The insurance companies sudden change of heart about Advair, after five years of use, was due to a controversial policy it adopted to reduce costs and maximize profits. Step therapy, or “fail first” policies, require patients to take an often less expensive medication with a completely different chemical structure from the drug the doctor prescribed, as long as the new drug is commonly used to treat similar symptoms.
Patients must document that the first medication failed before the insurance company will pay for progressively more effective drug treatments. Patients may be required to wait years and take half-a-dozen different drugs before they may access the drug their doctor recommended.
Insurers claim fail first protects patients from complex, new drugs that may have dangerous side effects that FDA testing overlooked, or that the policy protects patients with a history of drug dependence from pharmaceuticals with a high potential for abuse. But the only evidence the insurance company has about the effects of the drug are from the rigorous trials the FDA required before approving it, and doctors—who know better than insurers of their patient’s risk of dependency—are already empowered to consider the potential for abuse when prescribing the drug.
For all fail first’s tightly managed treatment regimens, the policy ends up costing more in additional physician consultations and trips to the emergency room, like it did for me when the insurer’s substitute gave me heart palpitations. Those extra visits add up and easily overwhelm any cost-savings generated by forcing patients to take cheaper, less effective alternatives.
By adopting a fail first policy, the very insurance company charged with guaranteeing my access to healthcare became my greatest obstacle to obtaining it. Fail first also undermines the authority of my doctor, who has been through years of specialized schooling and rigorous certification exams, and who knows me, my medical history and my unique physiology and considered all these things when writing the original prescription.
Insurance companies that have never met or examined me—but, who will gladly take my monthly payments — should not have the final say on the treatment choices I make in consultation with my doctor. Lawmakers need to restrict fail first policies and tell insurance companies that cost-savings may never come at the expense of a patient’s care.
Natalie Blake is the Director of Programs and Services at the Multiple Sclerosis Foundation.
Read the full article here.