The past few years have brought about exciting yet challenging changes to the health care industry.
In terms of treating patients, we have made significant advances and now have multiple medications. I’m a rheumatologist, and the symptoms that my patients face can be daunting and life-altering with pain, deformity and fatigue. Often these treatments can mean the difference between remaining employed and becoming disabled. In order to achieve good, timely outcomes, patients need to have access to the appropriate medication I prescribe for their individual condition.
Sadly, just as we’ve seen advancements in treatment options for our patients, we’ve also seen an increase in barriers to accessing these treatments. One such barrier is known as step therapy or “fail first.” Haven’t heard of it? Here’s how it works. Doctors prescribe a medication for a patient, based on multiple factors, including their medical history, reactions to previous medication prescriptions, and most importantly, medical expertise.
The problem comes when the patient goes to the pharmacy to fill the prescription.
Often, patients are told that their insurance company will only cover the cost of the prescribed medication after the patient has tried medications chosen by the health insurer. This goes against doctor’s wishes, and can often mean delays in care and worsening of the patient’s condition. What’s worse, if a patient has changed insurers, due to a new job or other reason, they can be forced to fail on medications that they and their doctors have tried before and didn’t work for the patient.
Specifically with rheumatoid arthritis, a disease that affects 20,000 New Mexicans, most insurance providers require that two medications from the same class be tried prior to changing. Multiple medical publications have shown that this is not the best option for the patient and delays recovery and worsens outcomes.