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Guest Column: ‘Fail first’ puts patients at risk

As a cancer survivor and a physician specializing in pain management, I understand the importance of prescribing the right medication at the right time. I also, unfortunately, have personal and professional experience with insurance companies interfering with a physician’s ability to prescribe the best treatment through a process called step therapy.

Often called “fail first,” step therapy is the practice where insurance companies force physicians to prescribe pre-selected treatments even if another treatment is what is best for the patient. The insurance companies claim to utilize “fail first” as a way to control costs but cost controls cannot come at the expense of patient health.

The Centers for Medicare and Medicaid Services (CMS) have recently announced a new policy that will allow Medicare Advantage plans to require step therapy for treatments covered by Medicare Part B.

This move will endanger the health of patients with serious conditions like cancer, rheumatoid arthritis and multiple sclerosis.

Under this policy, Medicare Advantage plans can force doctors to prescribe pre-selected treatments even if they are potentially less effective. Only when those initial treatments fail can patients move on to the treatment recommended by their physician.

Vulnerable patients with serious health conditions should not be forced to watch their health deteriorate because their Medicare Advantage plan is making them undergo ineffective treatment. Part B drugs cover complex biologic treatments administered by a physician that do not have a true generic substitute. Even if they treat the same condition, biologics are not interchangeable because their unique chemical compositions make them affect patients differently.

Medicare Advantage patients shouldn’t suffer at the hands of insurance providers’ cost-cutting measures. When my patients fall victim to the arduous step therapy system, I join forces with them to battle the approval processes until they receive coverage for the right treatment plan — without substitutions.

The new CMS policy will ensure that my patients and I will be fighting many more such battles in the future.

—Dr. David Russo is a physiatrist and pain management specialist in private practice at Columbia Pain Management, PC, in The Dalles and Hood River.


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