Patient Access of Florida

In the News Janet Shaw: With mental illness, there’s no time for ‘fail first’

As the state of our nation’s mental health-care system becomes a matter of public debate, it’s important for policymakers and the public to understand what is being done to help those who suffer from mental illness and what barriers stand in the way of better treatment. One such barrier is an administrative practice used by many health insurers called “step therapy.” Step therapy delays or prevents effective treatment for many of our most vulnerable patients.

Step therapy is when a medical provider — a psychiatrist or a family doctor, for instance — sees a patient, diagnoses a mental health issue and writes a prescription, and then the insurance company denies coverage based on the cost of the drug. The insurer instead requires the patient to try a different, less costly medication and “fail first.”

That is the actual term used in the industry, “fail first.” When that happens, the patient may be required to try a second substitute medication and fail on that before he or she can get the medication the doctor prescribed in the first place.

This is most concerning when applied to mental health problems. Research and experience show that treating mental illness at its earliest onset with the most effective psychotropic medication produces the best results, not only for the patient but for the family and the community.

Patients required to step through two ineffective medications will spend a month or more suffering with unresolved symptoms before the drug recommended by the doctor is even available to them. It may take another three weeks or so for the proper treatment to fully take effect. Many difficult, painful things can occur in this time. Mental health-care providers see them all the time: injury, family disruption, homelessness, incarceration, suicide.

This is not even the worst case situation. Psychotropic drugs are difficult to prescribe. The effectiveness of a given drug can vary depending on age, race, medical history and other factors. Doctors take all these issues into account in choosing a medication, but it’s still critical to monitor the patient closely.

If the medication is not working as expected, changes can be made. Only step therapy gets in the way again, and there’s further delay in getting the patient the treatment he or she needs and more chances for adverse consequences in all aspects of the patient’s life.

Physicians specializing in the treatment of mental health disorders need better access to the most effective prescription medications, not barriers. We have thanked the state of Ohio for allowing psychiatrists registered with the state to bypass pre-authorization procedures so they can quickly provide Medicaid patients with the treatment they need. We have asked that other providers, like family doctors, be given this access as well.

Step therapy is pre-authorization taken to extremes. And it’s not just mental health patients who are affected. Medications used to treat diabetes, arthritis, multiple sclerosis and even cancer are subjected to the step therapy process.

Patients with illnesses of many kinds are being required to “fail first,” essentially to let their condition get worse, by people who will never see them in person and have no training to diagnose their conditions. This is unconscionable.

Fortunately, a proposal to lower the step therapy barrier is under consideration in the Ohio legislature. State Sens. Peggy Lehner, a Kettering Republican, and Charleta Tavares, a Columbus Democrat, are working on legislation which would place some restrictions on step therapy. It would require insurers to use guidelines developed by medical professionals. It would define some circumstances in which step therapy is not allowed. And it would give doctors and patients a clear, defined way to appeal step therapy decisions.

Cost-containment is a legitimate issue in the health-care system, and restricting who can get certain medications is one way health insurers are addressing the problem. But step therapy is a problem in itself when it allows medical and mental health conditions to worsen, leading to spending on emergency room visits, hospital stays and other societal costs in places like our school systems and the criminal justice system.

Shaw is the executive director of the Ohio Psychiatric Physicians Association.

See the full article here.