Bad Medicine: Having to fail before one succeeds

Monday, December 19, 2011

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NEW YORK -- by Seth Ginsberg

I hope they're building patient exam rooms larger these days, because there are others who now join me during my visits to the doctor. They're with me, in the exam room and invisible at the time, but I know they're watching. So, naturally, I don't hesitate to use the ugly gown provided. And for the record, I'm not referring to the shy second year resident from another country doing a rotation abroad and shadowing my doctor. I'm joined by the silent, ubiquitous insurance company representative waiting for the next opportunity to tell me (and my doctor) what course of treatment is most appropriate.

The premise of this policy, and how they justify doing it, is through "fail first" or "step therapy" -- the practice by which I am denied coverage of one medication until after I have failed on a cheaper, often less effective drug. They say it's for my sake, but I don't see how this makes me any healthier.

From GHLF to the Rheumatologist:

It's inappropriate, inefficient, and -- for those of us living with pain, or worse -- a systemic autoimmune condition doing irreversible damage every day left untreated. We're being harmed unjustly. And for what? To save money by applying across-the-board policies that use formulas with predetermined medications, in addition to criteria for failure, before the initial treatment can be covered.

I don't understand how it's proper to have to fail before you're able to succeed. And I'm not alone -- our organization, the Global Healthy Living Foundation (http://ghlf.org), a 501(c)(3) advocacy group, represents large groups of patients (with arthritis, for example, within our popular patient community CreakyJoints, http://creakyjoints.org) who are put through this fail first practice every day. And to address this, we created the grassroots mobilizing campaign "Fail First Hurts" (http://failfirsthurts.org) to make the public more aware of how wrong this is and hopefully impress upon state legislatures why they should get involved to make this egregious practice illegal. And it's working. We're beginning to see success -- or the beginning of success -- in California, New York, Louisiana and Missouri, with other states including Ohio, Texas and Florida on the horizon. By making patients aware of this website, we can begin to take steps with a unified voice (doctor and patient) against fail first practices.

Recently, I sat down for a cup of coffee with Dr. Yusuf Yazici, a rheumatologist from NYU's Langone School of Medicine, to try and understand a physician's point of view on the subject.

Seth:		Do these "fail first" practices by insurance companies impact the way you practice medicine? How?
Dr. Yazici:		Every day. Especially given the types of conditions rheumatologists treat, most don't have approved therapies. The effort to argue and convince insurance companies is a big burden. It is hard enough to have an educated discussion with patients to explain and discuss with them the appropriate treatments and, on top of that, trying to reason with a bureaucrat at an insurance company where the aim is to deny care. It makes for a difficult combination. In addition, a "cookbook" approach may work in engineering but not in medicine. Every patient is unique and what they need will change any given day. It has to be recognized that even very well done clinical trials -- upon which most of our recommendation are based -- are flawed and only apply to groups of patients, not to individual patients about whom we need to make treatment decisions.
Seth:		How does it feel to be dictated to, by an insurance company, on how you treat a patient?
Dr. Yazici:		Of course not good. Treatment decisions need to be made between a caring physician and an educated, trusting patient. Anyone that interferes in this relationship harms the patient-doctor bond.
Seth:		What are some examples of when this is very serious and thoroughly inappropriate?
Dr. Yazici:		We commonly see this in biologic agents we use for the treatment of various immune diseases.
Seth:		What is the cost -- in dollars and time -- to your practice, by following these fail first policies?
Dr. Yazici:		There is great loss of time. The amount of correspondence the doctor and office staff have to prepare, submit and follow up on ... leads to countless hours of useless work that could be spent actually caring for patients and/or at the least reading more, educating ourselves and our patients. Doctors are forced to become paper pushers, which is not in the benefit of any patient or our healthcare system in general.

Seth Ginsberg is an arthritis patient and co-founder of CreakyJoints (http://creakyjoints.org), a 44,000-member/patient community that is a part of the Global Healthy Living Foundation (http://ghlf.org). The GHLF advocates for improved access to care by mobilizing patients to overcome barriers to care in local grassroots settings as well as through social and mobile media.

Yusuf Yazici, MD, is the Director, Seligman Center for Advanced Therapeutics at the New York University Hospital for Joint Diseases.

Contact Information:

Seth Ginsberg
Fail First Hurts
515 N. Midland Avenue Upper Nyack, NY 10960
+1 845-348-0400
sginsberg@ghlf.org

Download Press Release (Adobe PDF, 250 KB)