THE BLOG
04/04/2012 07:10 pm ET | Updated Jun 04, 2012

Patients Shouldn't Have to Fail First

During the battle over health care reform, we heard time and again that there would be "death panels" if the Reform Act were passed. The outrage was based upon the misguided notion that decisions regarding health care would be made by government bureaucrats rather than by doctors and their patients. Yet for years we have been allowing bureaucrats at health insurance companies to determine the course of care -- over the recommendations of doctors -- for too many New Yorkers. Bureaucrats are not doctors and they should not be making decisions that practically constitute practicing medicine without a license.

Step Therapy or fail first policies are practices which require the least expensive drug in any class to be prescribed to a patient first, even if that patient's physician believes a different therapy is medically in the best interest of the patient. There are currently no time limits or restrictions placed on fail first policies. Patients, including those with serious medical conditions, can be required to fail for an indefinite period of time before the agent preferred by the physician can be prescribed. This practice has the potential to result in serious negative consequences for consumers and the public health system. By limiting the array of medication options, both physicians and consumers are forced to compromise their treatment decisions in a way that is dangerous, time consuming and more expensive.

The application of these policies can result in the ridiculous -- as demonstrated by the application of first fail policies to birth control. Yes, birth control. While bleeding and nausea were considered failures, I don't need to explain what failed birth control really means. This particular application of the policies has thankfully been rescinded. Similarly, the New York state budget addressed the issue with respect to atypical anti-psychotic drugs for Medicaid patients in the recent budget by restoring prescriber prevails rules for those drugs. Yet, those who have been diagnosed with lupus, Lyme disease, multiple sclerosis, rheumatoid arthritis, or a host of other diseases and conditions, as well as people who have private insurance, do not have the same protections.

Unfortunately, the results of fail first are not just ridiculous. They are often cruel. We must not forget the human side of this policy. Fail First and Step therapy policies often require patients -- human beings -- to suffer: with pain, with side effects and with the fear that they will never get the treatment they need. These policies allow Insurance companies prey on and profit most from those who suffer with ailments that make it difficult for them to fight back.

I have heard far too many stories about people who have been tortured -- and I do not use that word lightly -- by unnecessary and unwanted treatments under this policy. I therefore recently introduced legislation (A.9397) that would, when medically in the best interest of the patient, create a clear process for prescribers to override the step therapy or fail first requirement of an insurance company. With the support of dozens of organizations, including the U.S Pain Foundation, the six Lupus Agencies of New York, the New York State Rheumatology Society, the National Multiple Sclerosis Society and the Medical Society of the State of New York, I am hopeful that we will pass this bill and give every New Yorker the right to have his or her doctor and not the insurance companies determine a course of treatment.