Phil Ammann
As a rheumatologist, I treat relatively common problems, such as osteoarthritis, osteoporosis, and rheumatoid arthritis. Other individuals have rare conditions shared by only a few people in the U.S.
When I am able to bring relief to my patients, my day has been successful. Two protocols used by insurance companies to reduce their costs — prior authorization and “fail first” — place a heavy burden on physicians and unnecessarily interfere with our ability to provide timely effective treatment.
“Fail first” or step therapy protocols require a patient to try the least expensive therapy first, despite what his or her physician recommends. After failing on the least expensive option, patients can finally receive what their physician originally prescribed.
These protocols can cause harm. For example, patients with chronic conditions, such as diabetes, mental illness, autoimmune, or cardiovascular disease, require proper drug treatments to stabilize their condition. Without these treatments, these patients will need more costly treatments such as hospitalization and can incur potential permanent organ damage and disability.
In my practice, I often see people who have osteoporosis with coexistent low kidney function. For some of these individuals, the generic oral drugs are inappropriate. They require an alternative therapy that is more expensive, but is approved for low kidney function. In this case, the “fail first” protocols do not work. I have no problem with effective, generic medications, but in some cases another drug is safer or more effective.
Every week, physicians’ offices are burdened with time-consuming prior authorization paperwork to ensure our patients are receiving the best course of treatment. There are multiple forms for each insurer and multiple forms for each drug.
Each time a patient changes insurance companies or pharmacy benefit manager, the physician is required to submit new paperwork for the same medication. Physicians need a clear pathway through the paperwork that is efficient and provides their patient with the best form of therapy with the ability to easily override the “fail first” protocols when appropriate.
Physicians need to focus on providing relief to their patient through immediate treatment options, rather than spending time on administrative tasks associated with “fail first” protocols. Patients and physicians should work together to determine the best course of action, without rigid protocols set forth by insurance companies and bureaucrats.
The best treatment option should not be interrupted by a health insurance policy with no provision for emergency back-up.
Our legislators need to make Florida a leader in creating a path for physicians to navigate the “fail first” processes that are essential to patient health. Without these protections, patients are denied the care they need when they need it. Physicians know their patients’ background and should have the ultimate say on which treatment the patient receives and when they receive it.
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Pamela Freeman, M.D., of Rheumatology Associates of Central Florida in Orlando, FL, is President of the Florida Society of Rheumatology. Column courtesy of Context Florida.
