Patients Irate With Insurers' 'Fail First' Policy

Are 'fail first' insurance policies a salvo for healthcare quality?

ByABC News
April 21, 2009, 7:49 PM

April 22, 2009— -- On March 16, 2000, Radene Cook, a reporter for radio station KFWB in Los Angeles, was hundreds of feet above the ground in a Cessna 172. During the flight, the single-engine plane was hit by a microburst -- a small, violent downdraft -- that sent it reeling toward the ground.

The damaged plane landed hard, and though Cook survived, she sustained a severe back injury. But Cook, now 42, said that the incident was only the beginning of her ongoing experience with chronic pain.

In what Cook describes as a four-year battle for pain relief, she said doctors with her workers compensation program relied on insurer guidelines to tailor her treatment. Rather than treatment with opioid drugs, she received rounds of steroid injections into her spine.

"There were 79 different needle punctures to my spine," Cook said, adding that each of the injections resulted in scarring. "The inside of my spine now looks like a Venus flytrap."

Cook was later diagnosed with a condition known as adhesive arachnoiditis, which she blames on the many injections she received. She eventually switched to a private health insurance plan and started seeing a new doctor in 2004. These steps, she said, allowed her to get the drug therapy she needed to control her pain.

"It took two years to titrate up to an appropriate opioid dose," she said. "Now I have a life back."

But she said that she believes the years of delay in getting this treatment were unnecessary. She blames a protocol commonly used by insurance companies, called step therapy, which is designed to lower costs and ostensibly provide higher-quality care. The policies are also called "fail first" policies by some, since the drugs must fail to help the patient before the patient receives coverage for a different option.

Even today, Cook said that she is in danger of losing coverage for some of the drugs she relies upon. And she is not alone in her dissatisfaction with the step therapy protocol. Cynthia Toussaint, another California-based pain patient, said she has had similar experiences. Twenty-six years ago, Toussaint, a former ballerina, began experiencing severe and unrelenting pain. Only later did she learn that her condition had a name -- complex regional pain syndrome, or CRPS.

"Eighteen years ago, my insurance company switched me from Axid, which I was using to treat CRPS in my vocal cords, to a cheaper medication," she recalled. "As a result, I couldn't speak and even experienced pain when whispering. I was forced to 'fail' on two cheaper medications before getting the medication my physician originally prescribed."

Toussaint said that she had a similarly negative experience when her insurance company switched her off her brand name Klonopin -- a pain and anxiety drug -- to a cheaper alternative that left her in pain and experiencing hallucinations.