As policymakers and health care
stakeholders consider reforms to address the cost of medications, Men’s Health
Network (MHN), the leading health advocacy and education non-profit for
advancing the comprehensive health of boys and men in America, urges lawmakers
and regulators to reject outright policies that will prevent or constrain
patients from accessing effective medications necessary to treat their diseases
and improperly insert themselves into the patient-healthcare provider
One such approach that should be avoided
is known as Step-Therapy but this process is more accurately termed Fail-First
therapy. This approach is a complex and drawn out type procedure that requires
a payer to give approval to the patient before a medication can be started
(known as prior-authorization). It requires that a
patient must try less expensive, usually older medications — which are
frequently have a higher treatment failure rate because they are less
effective, have more potential side-effects or less convenient dosing — before
allowing the patient to receive the drug their health care provider recommended
based on the patient’s individual needs.
a practicing clinical pharmacist and former pharmacist educator, I have seen
firsthand the potential problems this Fail-First approach to care has on
patients, the lost productivity it leads to, and how it not so subtly
undermines the relationship between health care providers and patients,
replacing it with a third-party organization (often a for-profit entity) at the
center of decision making.
an adolescent child that has been diagnosed with diabetes. Their health care
provider assesses the child’s specific needs, prescribes an appropriate
treatment plan and recommends the best diabetes medication for them. However,
the family’s health insurance won’t cover that drug, instead insisting on only
paying for a different, older and less expensive option. The patient must start
on this insurance company‘s “preferred” drug and wait for the drug to fail
before being permitted to try the medication originally recommended by their
physician. Worst of all, this cycle could happen many times over several weeks,
months or even years before the patient is finally able to access the originally
most agree that a Fail-First strategy is inappropriate for so-called “life
threatening” conditions it is sometimes very difficult to appreciate that even
common medical conditions, such as high-blood pressure, diabetes, and lung
conditions such as COPD if not treated effectively quickly are
life-threatening. Just look at the
mortality figures where these four conditions are among the top 10 causes of
death in the US. The refusal of
insurance companies to provide the originally prescribed drug ultimately leads
to a patient receiving less efficient care, suffering longer than they need to,
letting the underlying medical condition progress and causing hardship for both
the patient and their caregivers. This is just not right!
protocol cook-book approach to prescribing medications is clearly geared to
saving money and profit margins for payers and not optimizing patient
care. This is short sighted and a penny wise, pound foolish policy.
if we applied such a Fail-First step approach to other areas of our lives? Imagine
if airline companies were directed to use older, less effective instruments and
wait for them to fail before using the newer, effective, and recommended parts.
The potential catastrophes and outrage that would ensue from an approach would
be overwhelming and yet, we are expected to be comfortable with that exact same
approach being applied to our health.
simply, the Fail-First approach to selecting treatments is a fundamentally
flawed and dangerous practice that values cost-cutting over the individual
needs of patients, the expertise and advice of the prescriber and effective
care early on in a disease process. Patients deserve the best chance of success
from the very beginning of their treatment, and stakeholders must work together
to make changes that improve our programs while also ensuring that patients
have access to the best quality care available, without having to wait while
their condition gets worse.
MHN believes that preserving patient-provider relationships and ensuring access to the full range of technologies available based on individual patient needs, not cost, must be the core principle of any health benefit plan.