Patients Irate With Insurers' 'Fail First' Policy

Toussaint's fight against chronic pain led her to start the pain advocacy organization For Grace. On Tuesday, For Grace and Healthy African-American Families appeared at a hearing before the Assembly Health committee as lead sponsors for the California bill, AB 1144, written by California Assemblyman Curren Price and aimed at prohibiting step therapy practices by health insurance plans for chronic pain patients.

"This Bill would prohibit health plans and insurers from requiring a patient to use a different pain medication than the one prescribed by their physician," Price writes in an article in the March 26 issue of the California political newspaper Capitol Weekly. "AB 1144 will put an end to patients in California being forced to endure weeks, months or even years of unnecessary pain and inappropriate treatments. The Bill would also prevent patients who have changed insurers from having to repeat the 'step therapy' process if they have already gone through it with their previous insurer."

What Is Step Therapy?

The basic idea behind step therapy is to start with the most cost-effective and safest treatment, progressing to more costly or risky therapy only if the current treatment is not effective. In theory, proponents say, the strategy both minimizes risks to the patient and keeps overall costs under control.

Robert Zirkelbach, spokesman for America's Health Insurance Plans, said that when it comes to the bigger picture, step therapy is a key element in making the country's health care system more efficient by creating a standard system of care from state to state. He said that this saves costs, and it also ensures that patients get access to therapies that have been proved to be medically effective.

"We see individuals with the exact same illnesses get drastically different treatment depending on where they live," he said. "Right now there is no correlation between the money being spent and the health outcomes being advanced. Our goal is to help guide the patient."

Dr. Forest Tennant, head of the Veract Intractable Pain Clinic and editor of the trade magazine Practical Pain Management, is also Cook's doctor. He agreed that in theory, step therapy is not a bad strategy. And he added that doctors have traditionally employed a form of step therapy, in which they would gradually increase the dose of a given medication for a patient who was not responding until they were able to achieve the desired effect.

Doctors Employ Different 'Step Therapy'

And even when it comes to designing a course of treatment, Tennant agreed that a cheaper approach is preferable, as long as it works for the patient.

"Given the cost of some of the medications I prescribe, I also want the patient to try the cheaper medication first."

But he said that the step therapy used by the health insurance industry is different in that it may actually place a preferred therapy out of reach of a patient. Particularly vulnerable may be pain patients like Cook and Toussaint, who have experienced success with a given medication but are switched to a different drug by an insurer.

"What we have today is a situation where a patient is knocked around in the system, usually after they've already tried something that works for them but which they can't have," he said. "All of a sudden, the drug that they have been taking for quite some time is pulled away from them -- because it is more expensive, usually.

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