Imagine if NASA’s plan for the moon landing was to intentionally fail first with the lives of astronauts. Only after failing would NASA then follow a plan ensuring a successful landing on the moon and the safe return of three astronauts. Thankfully, 50 years ago, NASA took great care to minimize risk and maximize success, inspiring Americans to believe if we can put a man on the moon, we can do anything.
Too bad health insurance companies don’t follow NASA’s lead.
In a practice known as “step therapy” or “fail first,” health insurance companies actually experiment with the lives of patients by substituting a new drug for the drug prescribed by the doctor, sometimes because the new drug is less costly or it’s simply negotiated as the preferred drug by a pharmacy benefit manager. This practice occurs if the two drugs share the same active ingredient or allegedly have no significant clinical difference. However, insurance companies are practicing medicine when they use “first fail” to force patients onto a new drug that was not prescribed by their doctor.
While patients often respond well to the drug substitute, unfortunately, there are times the doctors already know their patients will fail on the substitute drug, which can cause harmful side effects leading to increased costly visits to the doctor’s office or the emergency room. It’s only after the patient reacts poorly to the new drug will the insurance company then cover the drug prescribed by the doctor.
When the new drug doesn’t work, it can be terrifying for families.
Shane, an 11-year-old boy from Egg Harbor Township, has type 1 diabetes. Two years ago, he was playing in a swimming pool when his blood sugar dropped rapidly, leaving him unresponsive. During what seemed an eternity, Shane’s mother forced sugary drinks down his throat, which did not revive him. As a last resort, his mother injected glucagon into his arm, which brought Shane back.
“It was the most traumatic and God awful experience,” Shane’s mom said.
Six months prior, in an effort to try out a new drug, Shane’s insurance company experimented with his medicine by switching his insulin prescription, which was working well keeping him stable for years. Within days of the switch, Shane suffered gastrointestinal upset, erratic blood sugar spikes and weight gain, so he went back to his original prescription.
Despite Shane’s negative reaction, the insurance company continued to experiment with Shane’s medicine and changed his prescription again over the objections of his doctors. Three times the insurance company denied the doctors’ request not to put Shane on yet another insulin, leaving Shane and his family powerless and with no other choice than to “fail first” on the new insulin, which this time nearly cost him his life.
Everyone agrees we need to keep health insurance affordable, but forcing patients to take a drug over the objections of their doctors simply because it may be cheaper is just wrong. This approach puts the patient medically at risk for side effects, which ultimately cost more money to treat.
Health care decisions should be made by doctors with their patients, not by accountants. As we saw in Shane’s example, individuals react differently to medications, which is why I introduced a bipartisan bill to protect patients from being forced off medicine that works and onto experimental medications because they’re cheaper.
First, the bill gives the benefit of the doubt to the family and their doctors by preventing health insurance companies from limiting, reducing or denying coverage for any drugs currently in use by a person covered under the plan. We put the burden on the insurance company, not the patient, to argue for a change in prescription.
Second, the bill requires insurance companies using “fail first” protocol to provide patients and their doctors with access to a convenient process, at no charge, to override the coverage restriction. Insurance companies have to cover the prescribed drug if the doctor believes the “fail first” is ineffective, will cause harm or has caused harm to the patient.
Many patients changing to a cheaper drug never notice a difference from their original prescription. However, for patients who have a history of adverse reactions to changes in prescriptions, like Shane, we need to protect them from medically unwarranted changes as well as provide them a path to leave “fail first” when it doesn’t work. NASA didn’t bet on failure, and neither should insurance companies with the lives of patients.
State Sen. Chris Brown, of Ventnor, is a Republican representing the 2nd District (nearly all of Atlantic County).