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Fail First Policy and Why it Will Likely Affect You Someday

Fail First policy, also called "step therapy," is the practice of forcing doctors to prescribe the least costly drug in any class to patients first, even if the physician wants to begin treatment with a different medication.
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Fail first policy. To the unknowing, it sounds like another one of those ill-conceived foreign policy doctrines, or possibly a method for dealing with the runaway deficit. It certainly doesn't sound like something that might end up affecting each and every one of us where it counts most, but that's exactly what may happen.

Fail First policy, also called "step therapy," is the practice of forcing doctors to prescribe the least costly drug in any class to patients first, even if the physician wants to begin treatment with a different medication. Medical insurance companies have devised this approach in order to keep costs down because if a patient responds to any of the cheaper medicines, the insurer has saved money. It can be a substantial amount of savings in the short run, depending on the drug in question. With health care in the news almost every day now, the policies and guidelines used by insurance companies have come under much closer scrutiny. At first glance, Fail First policy may seem innocuous. After all, who can be against keeping medical insurance premiums down, and possibly making health care cost less for all of us? Well, there is another side to this story, as there is in every great debate.

First, there is the patient to consider. While there is a chance that one of the lesser expensive medicines may succeed in helping the patient, there are real-life reports of patients who had to suffer through the long and tedious process of trying medication after medication in order to end up at the treatment that was denied in the first place. Of course, there are fiscal concerns we must acknowledge, but is there a price that can be put on pain and suffering? I'm sure there are a few attorneys out there who would say yes, but if you are the recipient of said pain and suffering, you might hold a different point of view.

Second, there is an argument to be made that the costs may actually end up increasing when using the step therapy policy. The time spent by the physician, the pharmacy, and the patient, prescribing, filling, and testing medications equate to money spent. In some cases, such as patients with auto-immune rheumatologicial diseases, just one of the drugs in the TNF-inhibitor class may take at least three months to show any improvement at all.

Costs can also be increased due to patients who are unable or unwilling to obtain the necessary administrative paperwork to begin therapy on their drug of choice. Insurance companies frequently require prior authorization before they will pay for costly medications, and auto-immune treatments are frequently costly. A study conducted by Pfizer found that patients treated under a step therapy program filled their prescriptions for anti-hypertensive (blood pressure) medication 7.9 percent less than those who were not treated with the step therapy protocol. The initial drug costs declined by 3.1 percent, but that effect declined in each subsequent quarter. Also, as the utilization of the drugs declined, the frequency of hospital and emergency room visits increased. When all was said and done, two years after the step therapy program was implemented, the step therapy patients incurred $99 more in overall costs per quarter, on the average. At minimum, further study is required before anyone can say without a doubt that fail first policy saves money, but the existing information seems to indicate otherwise.

Last, there is an argument to be made that the insurance companies are actually practicing medicine without a license. In Maryland, a study conducted by MedChi last year indicated that 95 percent of Maryland physicians surveyed said that the protocols implemented by medical insurance companies affected how their patients were treated. Over 88 percent of those doctors claimed that insurance practices such as pre-approvals, step-therapy, drug switching, and the like, were "burdensome," "very burdensome," or a "major hassle." The time factor comes into play once again, as one-quarter of the doctors reported that their staff spent anywhere from 21 to 60 hours per month interacting with insurers to obtain necessary paperwork and prior authorizations. The most eye-opening statistic shows that almost 77 percent of the doctors surveyed had considered moving their practice to another state or making their practice pay-for-service only, thus avoiding the hassles and administrative burdens placed on them by the insurance companies.

Medical Insurance companies have been at the center of controversy as of late, and it is due in no small part to the effort of this administration to provide health care for all. Some say that it is simply fashionable to take shots at the insurers, but as you can see, there are valid, factual, concerns to be considered. We all understand that the root cause is simply to save money and turn a profit, but the patient must be paramount in all considerations. You may not think that any of this will affect you, but when you turn that golden age of 65, you too will have to deal with Medicare or its equivalent (assuming it is still around). While there are groups out there fighting to make these insurance practices illegal, we need to do more. The people at have an advocacy group that is crusading to change the law in as many states as possible, and they have even succeeded in Louisiana. A victory, to be sure, but we need to educate as many more people as possible. You must decide for yourself, in an argument all sides must be considered. What price can we put on the patient's health, though?

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