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Palm Beach Post: “Fail First” policies undermine quality healthcare

As the Senate gets set to vote on the Better Care Reconciliation Act, it must consider including limitations on the ability of insurance companies to overrule doctors’ prescriptions and require patients take cheaper, less-effective treatments. I have experienced first-hand how this game of trial-and-error of health care can impact patient treatment all in the name of insurance industry profits.

I was diagnosed with hepatitis C in 1997. The disease has caused stage IV cirrhosis of my liver, which is life-threatening. My doctor prescribed a combination of interferon and a new drug, ribavirin. Ribavirin had only been approved by the FDA the previous month, so my insurance company denied the doctor’s request for the drug. They wanted me to take just interferon for a year and “fail first” on it before agreeing to pay for the combination treatment. This second-guessing of my doctor’s treatment — chosen after careful consideration — seemed to ignore that over 18 percent of patients with stage IV cirrhosis die within the first year. There was a decent chance I did not have a year to spare testing whether interferon would work.

“Fail first” policies, also known as “step therapy,” require patients with a condition to take a medication with often a different chemical structure from the drug the doctor prescribed, if it is less expensive and commonly used to treat similar symptoms. Patients must document that the substitution failed before the insurance company will pay for progressively more effective drug treatments. Patients can go years switching through half a dozen different drugs before their insurance company will pay for the medication the doctor originally recommended.

As in my case, insurers claim fail first protects patients from new drugs that may have dangerous side effects. But in fact, their real concern is whether they can save money by finding a cheaper method of treatment regardless of its effectiveness. Although the insurance company does not have independent evidence of potential side-effects, they do have the results of rigorous trials the FDA required before approving the drug.

Even though fail first is designed to reduce insurance company costs, in the end, the policy ends up costing more because of the additional physician consultations and trips to the emergency room from unexpected complications.

But, the real tragedy of fail first practices is putting our health care decisions into the hands of a corporation rather than our doctor.


Editor’s note: Pam Langford is President of H.E.A.L.S. (Hepatitis Education Awareness and Liver Support) of the South.

Read the full article here.