For patients with heart disease, getting on the right medicine quickly can mean the difference between a fatal cardiac event and another day doing what they love.
But for some patients, their health insurers’ onerous step therapy protocol will require that they try the insurer-preferred treatment before gaining access to their physician-prescribed one. The process, also known as fail first, unnecessarily exposes patients to serious, life-threatening risks like heart attack or stroke.
One Size Doesn’t Fit All in Heart Care
The process is scary and frustrating for patients and their caregivers as well as their medical teams.
A survey of over 350 stakeholders revealed that nearly all respondents believe medical decisions should be guided by physicians, not insurance companies. Yet step therapy protocols challenge physicians’ medical expertise, forcing them to navigate burdensome appeals just so their patients can receive the personalized care they deserve.
Heart health is individualized, taking into account each patient’s pre-existing conditions, genetic predisposition and other medications. In contrast, insurers’ protocols are generally one-size-fits-all and often designed to be low-cost. And jumping through insurer’s hoops may also lead to costly adverse health outcomes.
Even those who don’t have a serious medical issue often experience a lower quality of life, as burdensome side effects like chest pain and fatigue can proliferate because of ineffective treatment. Patient advocate Angie, for example, who lives with familial hypercholesterolemia, went through a period of adverse side effects after being subjected to her insurer’s frustrating fail first process.
Recommendations to Put Patients First
Good public policy can minimize the dangers of step therapy.
The American College of Physicians has urged lawmakers to prioritize patient safety by minimizing step therapy delays, listening to physicians and ensuring appeals are handled promptly.
Acquiring transparent data on the effects of insurers’ step therapy policies and their deleterious effects can also help drive reform. Some states have made significant strides toward protecting patients, but federal actions have yet to materialize despite the burden of untreated disease.
Patients and Doctors Should Decide
Heart disease remains the leading cause of death in the United States, with one heart attack occurring every 40 seconds. No patient should be subjected to unnecessary suffering from ineffective treatment when superior options are available. Policymakers and insurers must work together, alongside patients and their advocates to put patients’ best interests, and physicians’ expertise, at the forefront of medical decisions.
