Prescription: fail

New law would prohibit insurers from denying needed pain medication

When someone has a medical condition that causes chronic pain, doctors are expected to prescribe medication to ease that discomfort. But patients are sometimes denied relief—at least at first—because of an insurance company practice called “step therapy” or “fail first.”

In order to save money and prevent drug dependency, insurers require some patients to try over-the-counter medications or weaker prescriptions before allowing more powerful medicine. If the lesser drugs fail, patients eventually receive stronger treatment, but sometimes not until years after the initial pain starts.

California Assembly Democrat Jared Huffman has authored a bill, Assembly Bill 1826, that would completely eliminate step therapy, on the grounds that it causes unnecessary pain.

“Why should the health plans be playing Russian roulette with your health and safety?” said Debra Gravert, Huffman’s chief of staff.

However, California Association of Health Plans CEO Patrick Johnston maintained that the insurers are actually the ones looking out for patients.

“Step therapy allows a patient to move from less-dangerous pain medications to more-dangerous pain medications in order to lessen the likelihood of dependency on medications,” Johnston told SN&R.

Loretta Jones, founder of the nonprofit Healthy African American Families, which supports A.B. 1826, disputed that. “When you really look at it, you see that people who abuse the substances are more people who have money and influence,” Jones said.

Jones added that step therapy is a problem that’s “pervasive among minority populations.”

The bill exempts health plans purchased through California Public Employees’ Retirement System (CalPERS), much to the chagrin of the private health insurers. An opposition letter from California Association of Health Plans argues that the proposed new law is too expensive.

“The best evidence of the high cost of this bill is that it completely exempts the CalPERS system,” the letter reads. “While this spares the public employers from the cost of this bill, it means that private employers will be expected to shoulder the cost instead.”

But Gravert said that the bill could actually end up saving money for both patients and their insurers, because of the unintended costs of step therapy.

“If they give you the cheaper drug and that doesn’t work, then you’re going to go back to your doctor, which is more expense. Your doctor is going to write another prescription, which is more expense. And then if they make you go through step therapy again … if you’re talking about someone with severe, chronic pain, where is that person going to go? They’re going to go to the emergency room, which is another expense,” Gravert explained. “You could go as far as people missing work because they don’t have the right medication because they’re in so much pain that they can’t get out of bed.”

But the California Association of Health Plans argues that doctors can submit a special request when necessary for medication not normally covered under a patient’s insurance. And according to the association, “About 90,000 to 400,000 people are harmed or killed because they received the wrong drug or used the right drug in the wrong way.”

For these reasons, insurance companies see completely eliminating step therapy as too extreme.

But to Loretta Jones, “fail first” is too extreme. “I was one of the people who had to go through step therapy. I have fibromyalgia, and going through step therapy with the pain was excruciating,” Jones explained. “Doctors are required to do no harm. That’s part of the Hippocratic oath. Part of ‘Do no harm’ is not to have a patient suffering.”