March 23rd, 2018

Continued access to a stable treatment can make all the difference for patients with chronic illnesses like arthritis, cancer, diabetes, hepatitis C, HIV/AIDs and more. Interruptions in treatment can lead to disease progression and unnecessary medical expenses like hospitalization or surgery. In rheumatoid arthritis, studies show delaying treatment can lead to significantly more joint damage than those patients who receive treatment immediately.

Unfortunately, in Massachusetts these devastating interruptions occur more often than they should because of inappropriate use of an insurance practice called step therapy or fail first. A fail first policy requires a patient to try and fail an insurer-preferred medication before covering the medication your doctor prescribes.

I have heard countless stories of patients having their treatments interrupted unnecessarily with harmful consequences. For instance, Anna Legassie, a rheumatoid arthritis patient from Dorchester whose treatment was denied by her insurer and who was forced to try and fail two different drugs that she had failed previously. She was confident that once her doctor provided the appropriate clinical notes indicating treatment failure with these drugs the decision would be overridden and she could proceed with treatment as planned.

However, her insurer’s step therapy protocol did not allow for her to appeal based on previous drug failure because she had not been on either of these drugs within the last 130 days. She would have to try both drugs again for a period of 12 weeks each, and, only after trying and failing drugs again, would be allowed to proceed with the original course of treatment prescribed. Frustratingly, her insurer could not give her any sort of timeline for an appeal or overview of the appeals process. Unfortunately, this situation is not uncommon in Massachusetts and this practice is in dire need of reforms.

Despite these potential dangers to patients, the use of step therapy is on the rise as insurers use the practice as a cost-saving mechanism. As of 2013, 75 percent of large employers reported offering plans that use step therapy. Yet, some studies have shown step therapy practices do not save money overall. While the insurance company may save by denying access to prescription medications, that patient may seek vital and necessary care in an expensive hospital or emergency setting. Remember, failing on a medication means that medication is not working for the patient.

In the meantime, a patient’s doctor may attempt to override a fail first policy through an oftentimes lengthy and cumbersome process before waiting for a response. Doctors have often told our patients that they sometimes need to employ staff solely to process these overrides and the insurer responses. The response could take days or weeks during which a patient may not receive coverage for their doctor’s recommended treatment.

A coalition of patient advocacy groups — 41 and counting — has been working on this issue in Massachusetts for 8 years. The bill is H1853/S1235: An Act relative to Fail First and Patient Safety. We are not asking that the practice be banned. Instead, we want the process to be more transparent and easier to manage for both patients and doctors. We want a doctor to be able to override a protocol in medically necessary circumstances such as if the patient has tried and failed on the drug previously or if the patient is stable on their current prescription medication. And we want insurers to respond to appeals in a timely manner.

Ohio just became the latest state to reform fail first protocols earlier this year with several other states considering similar legislation.

At least 21 states have already enacted laws reforming step therapy practices so that patients can get faster access to the medication their doctor knows has the best shot of working. In a state that is known as a leader when it comes to healthcare, with some of the best doctors and hospitals in the country, why are we not putting patients first?

– Ben Chandhok is senior director of legislative affairs for the Arthritis Foundation.