By Paul Gileno
October 19, 2016 at 5:00 am ET
While high drug prices are dominating the headlines, a more dangerous phenomenon is playing out behind the scenes – insurer obstruction in medical decisions. I was a victim of this particular brand of injustice. It is ensnaring patients daily, though many may not be aware of the practice until they are caught in its trap.
Most Americans would agree; the insurer has no place within the sacred doctor-patient relationship. We trust our doctor to be the arbiter of our health and when a doctor makes a recommendation, it is done with extensive knowledge of the patient’s needs and the motivation to better that patient’s life.
There is a mounting barrier to treatment resulting from health insurers utilize their power to deny needed medications. The reasoning? Cost savings at the expense of a patient’s health. To gain medication coverage, patients must adhere to the insurer’s recommendation of a lower-priced and often less effective medication.
Known as “step therapy” this iniquitous practice is one of the reasons I launched my foundation. Step therapy, also known as “fail first” is when an insurer decides a patient must first prove failure on a cheaper, potentially less effective medication before approving the originally prescribed medication. While I learned this was an accepted practice among insurers; it seemed unreal to me that a doctor could prescribe a treatment only to have the insurer ignore his advice.
My pain journey started while operating my own catering business. I thought I was simply lifting a box; but, I twisted incorrectly, snapped my spine, and severed my left sciatic nerve triggering the beginning of my chronic pain journey. I had therapy and three surgeries before realizing my back was never going to heal.
I wasn’t going to let a life-long diagnosis deter me. I needed to do something to reduce my pain and get on the right track. While filling my prescription, recommended by my healthcare provider who understood my condition and medical history, I discovered there was an opposing force at work. My own health insurer, who I was paying twice monthly, had other ideas. They refused to cover the medication my doctor deemed medically necessary, claiming they’d only cover alternative treatments.
A self-defeating time in my life which caused depression, I wanted to know why and how my insurer could do this. I waited for months and failed on two medications until my insurer had the confidence that the higher price tag was warranted for my health. During what was undoubtedly the most chaotic time and one that would indefinitely impact my well-being; the insurer was trying to regulate choices that are best made by the doctor treating me.
While insurers don’t have intimate knowledge of your health, they do have the self-imposed authority to override doctors’ decisions. How is this legal and why would insurance companies do this? Simply put, because no one is stopping them. Though doctors argue with insurers regarding the recommended treatment of their patients and many now employ staff specifically to fight with insurers on medication denials, no one is policing this practice.
I soon realized that I was not alone. In 2011, I went a step further to unite patients and launched U.S. Pain Foundation nationally as one way to engage others to advocate. Patients with the same step therapy battles were joining the organization to fight for fair legislation.
There are now several states with laws that limit step therapy practices. In Connecticut, step therapy legislation was signed into law in 2012 and later strengthened to encompass not just chronic pain patients, but all patients. U.S. Pain Foundation was instrumental in the passage of bills aimed at curbing step therapy practices were turned into law within the states of Indiana, Missouri, Illinois and West Virginia. Step therapy legislation in New York is currently awaiting the governor’s signature.
That said, many states are still without patient safety safeguards against step therapy. It is defeating for patients who feel that glimmer of hope when holding a golden ticket– that prescription for medicine that will manage their condition — but they can’t have it.
As someone who was a victim and is now an advocate for chronic pain patients, I’m asking for others to come forward and say, “no” to this abusive practice and lawmakers to take action. Health insurers should embrace our health needs. They should not have the power to make it worse. If this isn’t playing a dangerous game with a patient’s life, I don’t know what is.
Paul Gileno is the president and founder of the U.S. Pain Foundation.
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