The Alliance for Patient Access / IfPA’s Patient Access Policy Blog / Patients Shouldn’t Have to “Fail First”

Patients Shouldn’t Have to “Fail First”

Imagine having severe eczema. Your hands, arms and feet are always red and irritated. Sometimes your skin is so dry it cracks. Other times you have weepy blisters.

Both extremes are unsightly and make shaking hands awkward. You feel less confident at work and in social settings. Not to mention distracted and tired because the itching is so unbearable that it’s affecting your ability to concentrate and sleep.

Like every patient, you talk with your doctor to determine the best plan of care.  But that doesn’t necessarily mean you can access the care your doctor prescribes. Even though you rely on your doctor’s knowledge and expertise to recommend the most appropriate treatment, your health plan may have its own opinion.

Many insurance companies won’t cover new, innovative treatments, even when a doctor prescribes them. That is, until the patient has failed first on the plan-preferred medication. It’s a practice known as “fail first.”

Unfortunately, thousands of patients with dermatological conditions such as eczema and respiratory conditions such as asthma experience this every year. So do those with cancer, chronic hives, diabetes, epilepsy, hemophilia, mental illness and a host of other chronic conditions.

Doctors prescribe what they believe is the best medication for their patient’s specific needs.  Their judgment is based on careful review of the patient’s medical history and personal interactions to examine the patient. But then health plans deny access to the prescribed treatment until the patient has “stepped through” a different, often-cheaper, medication first. This practice is also called “step therapy.”

The tactic is a cost-saving measure for health plans, but it can be detrimental to patients. And in many states, there is no clear appeals process for those who want to challenge the “fail first” requirement. Meanwhile, patients’ conditions can worsen and their health can deteriorate as they try and fail on medications that don’t work for them.  This often leads to additional office visits and may lead to emergency care or hospitalization for certain chronic conditions.

There is good news, though. Some state lawmakers are advancing policies that change how health plans can administer step therapy.

More and more states have enacted laws to establish the sequence of events considered medically appropriate to exempt a patient from failing first on a prescription medication protocol, based on clinical review. This provision is critical, because step therapy programs imposed by health care plans result in as many as one in five patients not receiving treatment at all. Long delays or lack of treatment can worsen health outcomes.

A number of states have enacted step therapy reforms with a transparent exemptions process. This means patients and health care providers have a recourse when health plans require a patient to fail first.  

Additionally, other state legislatures have passed laws to clarify that fail first protocols are based on clinical guidelines developed by independent experts, in order to keep health plans aligned with medical recommendations —not strategies to boost their bottom line.  

Reforming step therapy is in patients’ best interest. My home state of Georgia did not manage to get step therapy legislation across the finish line this year, but other states did.  New Mexico and Minnesota, for example, have now joined the growing list of states whose legislators have put step therapy reform laws on the books.

Patient and health care provider organizations remain committed to these efforts, and with good reason.  Only when all states have enacted appropriate protections can we ensure that a doctor’s medical expertise and firsthand knowledge of a patient’s medical condition is not bypassed by insurance companies’ one-size-fits-all, cost-oriented approach.

###

Michael Blaiss, MD, an allergist-immunologist, is the current executive medical director for the American College of Allergy, Asthma, and Immunology.  Dr. Blaiss is a member of both the Derma Care Access Network and the Alliance for Patient Access.

About AfPA Digital

The Alliance for Patient Access is a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care.
Back to Top