Insurance-driven “fail first” policy hurts patients, undermines doctors

Every day, I get up, go to work and fight hard to ensure Texans with disabilities can live, work, learn, play and participate in the communities of their choice.

At home, I fight for my Mom, Binky Hughes, who lives with me and suffers from several complicated health issues. Over the last several years, her ongoing battles have earned both of us a close working relationship with her primary care doctor and a number of surgeons and specialists.

My sweet 65-year-old Mom, you see, suffers from Chronic Obstructive Pulmonary Disease, or COPD, and depends on oxygen and medicines in order to draw a simple breath, an action most people take for granted.

She also lives with other medical issues including schizophrenia, diabetes and bi-polar disorder, and recently went through a leg amputation caused by her diabetes. Individually, each of these issues is complicated and makes for a tough road. Taken together, they can amount to a significant and daily struggle — but we are fortunate to have strong Medicaid coverage and a great team of professionals around us.

Not long ago, we were all put to the test when our Medicaid HMO insurance company didn’t want to pay for a particular medicine that Mom needs in order to breathe. This medicine was prescribed by my Mom’s doctor, who has treated her for ten years and who understands her complex medical history.

It took us six months of frustrating effort to finally get this medicine covered for my Mom. It also took failing on two older, cheaper medications — medicines the doctor did not prescribe. These older, less effective drugs made Mom shake and twitch and led to several preventable accidents because she was unsteady on her feet.

This situation is familiar to many patients and has a name: step therapy. It’s a system in which an insurance company forces patients, as in our case, to start with older, cheaper, possibly less effective, medications before they will agree to financially cover a newer, potentially more expensive medicine, regardless of what is initially prescribed by the treating physician.

This policy is also called “fail first” because the patient’s health must literally “fail” on several medications before the more expensive one is approved. “Failing” for my mother led to preventable accidents as we “failed” on several drugs for six months. Living through this incredibly poor health care situation was heartbreaking, infuriating and completely unavoidable.

I wouldn’t wish this situation on anyone, certainly not someone whose health is as fragile as my Mom’s.

Sadly, right now, a group of health insurers want to engrain this heartless policy into law by winning full control of the pharmaceutical benefit in Medicaid. My hope is that lawmakers will reject this proposal and instead choose to protect patients like my Mom.

Our elected leaders should ensure that doctors, not insurance companies, remain in charge when it comes to prescribing medicines for Texas Medicaid patients.

Erin Jones, Coalition of Texans with Disabilities

Erin Jones is a CDS Claims Specialist for the Coalition of Texans with Disabilities.