Common sense is a big thing in our state. We like to call things as we see them and so it is with the debate surrounding an insurance industry policy called step therapy or fail first. As a doctor, I’ve seen patients successfully treated with a drug for years, now being told by insurance companies they won’t cover the prescription until the patient tries and fails on other drugs first. Insurers say fail first saves consumers money, but the reality is, it’s injecting dumb and dumber into the prescription process.
The phrase, “Doctor, I just changed insurances which will save me a ton of money,” sends chills up any physician’s spine. We know what comes next is both frightening and worrisome. Patients discover medications that have controlled their heart disease, hypertension or diabetes are no longer covered, and their new plan moves them to a higher tier requiring prior authorization. Cheaper medicines pushed by insurers often don’t equate to better outcomes and patients don’t realize specific drug regimens must be delicately balanced to improve health.
Such is the environment that insurance companies have tossed their “fail first” concept into in Iowa. They abruptly yank a patient’s prescription coverage and force them to try several new drugs and fail on those first. All this, while the patient, whose condition was being successfully managed, deteriorates. That is exhaustive, debilitating and terribly upsetting to patients and doctors who have worked so hard to get these individuals to a level of good health.
My staff and I have encountered numerous insurer “fail first” delays, even though we have pleaded with insurers not to do this. They’ve put us on hold for weeks and no one seems to care. When, and if, we are lucky enough to finally speak with the correct person, the problem can be resolved. Recently, one case took eight days, 18 calls, three appeal letters and an attempted effort to get a peer-to-peer consult. Amazingly, on the day my patient’s prescription was finally approved on the phone, the insurer rejected our appeal by mail. They informed me I could not appeal their decision on behalf of my patient without a formal declaration by the patient. They also kindly included a large packet of forms to be filled out. What a mess.
Fail first creates a numbing, time-wasting bureaucracy of roadblocks for doctors. It also treats patients like numbers, not humans. As we are forced to slog through fail first, time passes and patients get sicker.
Thankfully, the House and Senate have passed HF 233 without opposition. That bill will curb the bad things in the fail first policy by putting exemptions and guard rails in place that allow doctors, and not insurance companies, to determine the best medications for patients. HF 233 makes real sense and now we need Gov. Terry Branstad to sign this legislation into law to protect the health of Iowans.
• Dr. Joseph Molnar is an osteopathic family physician in St. Charles.