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Insurance Discussion - Illustration via iSTOCK
June 28, 2021

Insurance providers should not be playing doctor

by Barbara Giesser

Legislature has the chance to change standards insurers use when deciding on medications patients are allowed to receive.

As a multiple sclerosis neurologist, I see patients with chronic medical conditions. While these diseases are not curable, they are treatable with appropriate strategies, including medications that can give patients their best chance at a full and productive life. The key is selecting the best medication for each individual patient.

Sometimes, however, the ability to make that critical decision is taken away from physicians by insurance companies that want patients to try other medications first. These medications may not be as effective as the one the physician has prescribed, and some have more potentially dangerous side effects.

This practice is called “step therapy” or “fail first,” because patients are made to try and fail on other medicines before they are allowed to get the medicine the doctor originally prescribed. Such decisions are made on the basis of what is best for the financial health of the insurance company, not what is best for the health of the patient. 

There are multiple problems with step therapy protocols. First, and most obviously, the decision about which medication a patient can have is not made by the patient’s doctor, but by someone who works for an insurance company. That person is rarely an expert in the patient’s disease, and may not even be a physician. If someone besides me is going to determine which medicine my patient receives, at the very least he or she should be a physician in the same field of medicine.

Therapy for neurologic disease, like many other illnesses, is complicated and nuanced and requires specialty knowledge. Treatments are not necessarily interchangeable. What works for one patient with epilepsy or multiple sclerosis might not work for another person with the same illness. Assessing the best treatment involves knowing patients, their medical history, their family’s medical histories, their emotional needs, as well as all the effects and side effects of the medications under consideration.

Second, step therapy causes treatment delays, which, in the case of my patients, can lead to irreversible neurologic deficit. Such delays affect patients with myriad other diseases, ranging from arthritis, Crohn’s disease, cancer, diabetes, mental illnesses and many other chronic conditions.

Fortunately, California lawmakers are on track to curb some of the problems with the step therapy process.  Assembly Bill 347 allows step therapy exemptions in certain situations, and mandates review decisions in a timely fashion. Especially important, it ensures that a clinical peer and practitioners in the same specialty as the prescribing physician make decisions involving medications on behalf of health plans.

Earlier this month, the Assembly passed the bill. California’s senators should be urged to do the same.

Original article: Guest Commentary on / illustration via iStock

About the Author

Barbara Giesser, MD

Barbara Giesser

Barbara S. Giesser, MD, FAAN, FANA, is an internationally recognized clinician and award-winning educator who has specialized in the care of persons with Multiple Sclerosis since 1982. Her approach to the diagnosis and management of persons with MS combines advanced diagnostics and a personalized medication plan for each patient with an emphasis on integrating lifestyle and wellness strategies into the neurologic treatment plan.

Last updated: July 2nd, 2021