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.
For patients dealing with lifelong, chronic conditions, this can simply be devastating – physically, financially and emotionally. I’ve had patients simply want to give up because the struggle to get what we believe will help their condition is kept out of reach by their insurer.
There is hope for patients in the form of legislation to put parameters in place around fail first. Last year, New Mexico’s lawmakers introduced legislation that would do just that – by requiring a clear and timely appeals process for patients and doctors when fail first is implemented by a health insurer. The bill would not have banned fail first but does give patients and their medical teams better ways to access medication in a timely manner.
It is my hope that our lawmakers can see the reasons for passing this type of legislation to support our patients. We all understand the challenge of reining in health care costs, but these sorts of one-size-fits-all solutions like fail first have the potential to do more harm than good – with serious, real life medical consequences for those I treat and thousands more across our state.
I urge our state leaders to follow the lead of states like Missouri, Texas, Iowa and others who have put fail first reforms into place. Doing so will be a step forward in protecting the health of New Mexico patients.