GUEST COLUMN: Insurers shouldn’t require patient ‘failure’

<p>Tony Radmilovich</p>

It’s a simple business and manufacturing rule: The right tool and the right process at the right time makes the right product. It holds true for the health care, too.

For years, I’ve been in search of the right tool at the right time.

My life has been changed by pain. About seven years ago, after suffering from debilitating pain in my legs, wrists, hands and arms for some time, my doctor prescribed medicine that managed to control my pain and allowed me to carry on a reasonably normal life.

This forced me on a long odyssey with doctors and pharmacies to help me live a productive existence and continue supporting my family.

After a few months of success in controlling the pain, my insurer notified me it would no longer provide coverage for that medicine unless I first tried at least three other, less expensive medications to see if they could be substituted.

At first I felt total fear as I knew that my present medication worked well and I was reticent to give it up. My doctor was apprehensive as well, saying that he had prescribed the original medication for good reason but since I could not afford it without insurance coverage, we had no choice but to try something new.

The tough reality I’ve learned is that health care still needs some reforming. The odyssey began with an increasingly used tool by insurers called “fail first.” I was being forced to actually fail on cheaper medications until the insurer would finally approve the optimal medicine for me.

It seems that health insurers can actually interfere with the doctor-patient relationship when they deny coverage for treatment. This fail first or “step therapy” can enable payers to override physicians’ care decisions and determine a patient’s medication regimen, oftentimes preventing doctors from prescribing a preferred treatment option based on their clinical judgment and knowledge of the patient.

This was as difficult a time for me as for my doctor. A few years ago, an American Medical Association survey found that more than half of physicians experienced difficulty obtaining approval for prescriptions on 25 percent or more of their requests. The majority of physicians also reported having to wait several days to receive approval.

As for me, I had no real relief from my pain during this time. I was having a very difficult time walking and even performing daily necessities. Though it was proven that two recommended substitutes were worthless to me, I was required to try yet a third medicine and endured another six weeks of agonizing pain that by now was preventing me from sleeping as well as working.

I often wondered if my physician’s hands were tied in trying to treat me with the most effective medicines available.

Finally, the insurer agreed to resume coverage of my original medication, which I still rely upon today. I, like many other patients, wondered why this exercise had been necessary. In the process, it also ended up causing several otherwise unneeded visits to my doctor which cost not only me extra expense for co-pays but my doctor’s and his staff’s time, as well as the insurer, who must now reimburse my doctor for my extra office visits.

Both my doctor and I agreed that his medical judgment and my choice as a patient, within the bounds of accepted medical practice, should take precedence over my insurer’s preferences in decisions about individual care.

This lesson has taught us that health care professionals must retain the ability to address the variability of patient responses and to individualize care through access to multiple treatment options. I’ve heard legislation is now under way in Oregon to put physicians in the driver’s seat in directing patients’ care, not the insurer company.

I am a story of unanticipated consequences. This is good news for me because I believe that my doctor’s first concern and responsibility is to my well being, and medical decisions affecting me should be left to him.

Patient Tony Radmilovich, of Bend, writes for a British aviation magazine. He has suffered from a myalgia-based chronic pain for many years. This column was distributed by Oregon Healthwire.

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