“Fail First” or “Succeed First?” It’s a pretty good proxy for the larger health care debate that pits short-term cost savings over long-term patient benefit.
A new bill in the California Assembly (AB 1826) addresses the issue of “fail first” policies (aka: “step therapy) and cuts right to the chase.
The bill “Requires a health plan or health insurer that covers prescription drug benefits to provide coverage for a drug that has been prescribed by a participating licensed health care provider for the treatment of pain without first requiring the enrollee or insured to use an alternative prescription drug or over-the-counter product.”
And it uses chronic pain as a specific example:
“Due to the variety of causal conditions and types of pain (acute and chronic), there is no standard treatment for pain. Pain treatment varies according to type, severity, and duration of pain, as well as the causal condition (if known), patient co-morbidities, and other factors (e.g., medication intolerance or patient compliance). Health care providers use clinical judgment to select among various pain medications and treatments in efforts to resolve or control pain for individual patients …For some enrollees, no pain medications are subject to fail-first protocols. Other enrollees, depending on the provisions of their plan contracts or insurance policies, have outpatient pharmacy benefits that make coverage for between one and 38 pain medications subject to fail-first protocols …Of more than 200 prescription medications used to treat pain, 54 are subject to fail-first protocols for at least some portion of enrollees with health insurance subject to this bill whose health insurance includes an outpatient pharmacy benefit.”
(The complete bill can be found here.)
One example of a group supporting this legislation is the California Medical Association. Opposed? The Association of California Life and Health Insurance Companies.
The repercussions of choosing short-term savings over long-term results, of cost-based choices over patient-centric care, of “fail first” policies over the right treatment for the right patient at the right time – are pernicious to both the public purse and the public health. Skimping on a more expensive medicine today but paying for an avoidable hospital stay later is a fool’s errand.
In California -- indeed across the entire United States -- access to care must be matched with quality of care.
