Should health insurers be allowed to make patients ‘fail first’ on the wrong drugs?

4.18.17

Chronic disease patients in Texas are speaking out in support of bills that would help to protect Texans against the harmful practice of step therapy.

Step therapy is a requirement, set by health insurers, for patients to try a cheaper drug than their doctor first recommends and to fail on that cheaper medication before they’re allowed to obtain the treatment prescribed in the first place.

Sheldon Metz, a non-practicing attorney and teacher living near Forth Worth, has multiple sclerosis (MS), an unpredictable and often disabling disease of the central nervous system. Symptoms range from numbness and tingling to blindness and paralysis. With the right medication, many people are able to manage the disease, prevent relapse and slow its progression.

Metz wrote in the Star-Telegram that, because of step therapy, “I still have not been able to take the medication my doctor believes will best control my symptoms and disease progression.”

“Immediately following my diagnosis, my neurologist prescribed an oral MS disease-modifying drug that had been recently approved by the Food and Drug Administration. Unfortunately, my health insurance company refused to authorize my doctor’s first choice for treatment and required me to try and fail on an older, injectable drug before they would cover the oral therapy,” Metz wrote.

The results have been catastrophic.

“Since my diagnosis and even while on the medication, I have lost function in my right hand, right arm and most recently my right leg. I now walk with a limp on top of the incredible fatigue and weakness often associated with MS,” he said. “In addition to not effectively preventing disease progression, the injections also have side effects. Every injection is painful, and I develop hard, raised welts that can last for weeks before eventually fading to a bruise. These injections also cause muscle atrophy at the injection sites, especially in my stomach and legs. That means I lose muscle mass around the injection site and am running out of unaffected areas of my body to give myself the shots.

“My hope is to eventually switch to the drug my doctor believes is the best choice for me.”

Metz urged Texans to rally support for two bills. Introduced by state Sen. Kelly Hancock and Rep. Greg Bonnen, the bills would “create a clear process to protect patients from being required to try and stay on a step therapy medication if (it) is not in their best interest.” They also would prevent patients who are stable on their medication from being forced to try a new, cheaper medication and would prohibit insurers from requiring patients to fail medications more than once.

“These commonsense protections are good for all Texans,” Metz wrote.

Protections such as these are increasingly important as health insurance companies target chronic disease patients’ benefits.

A similar bill recently advanced in Florida. You can read more about the Florida initiative here. Sheldon Metz’s full column can be read in the Star-Telegram.