Important steps to protect patients
Every now and then, adrift in the sea of health care reform dialogue, emerges a life raft of positive change and progress.
That’s exactly what happened during this past legislative session when Vermont legislators — spearheaded by Sen. Kevin Mullin and Rep. Michael Fisher — took an important step to address some of the problems associated with the well-established practice of health care rationing.
Insurers have been rationing health care for years without regard for the well-being of the patient. They just don’t call it rationing. When an insurance company denies you access to medication prescribed by your doctor, or coverage for a test or a procedure, that’s clearly a form of rationing. When Medicare cuts payment to doctors across the board in one fell swoop, we are rationing care again. It’s likely you’re paying more out of your own pocket for your health care — insurance rates are increasing each year, despite your greater out-of-pocket expense.
There’s no doubt we have to cut health care costs. But in our quest, it’s important to keep medical decisions in the hands of medical providers, and that’s exactly what Vermont’s new health care legislation does. There are three elements to this new law that will make a big difference to patients.
First, you may have been frustrated in the past by the insurance delay game, also known as “prior authorization.” This is the process of allowing someone who is not your health care provider, who is likely in another state, who may or may not have strong medical credentials, to make an important decision about which medication you will put in your body, based on a formula out of a book that a committee at the insurance company agreed upon. It can take weeks for your doctor to get the insurer to agree to cover the original prescription. The new law requires insurance companies to respond to patients or their providers within 48 hours after a request for coverage for a medication is received (24 hours in urgent cases).
Second, lawmakers have regulated the practice known as step therapy, or “fail first.” Fail first happens when the insurer rations your care by forcing you to try, and fail on, several cheaper medications first, before agreeing to pay for the medication your doctor actually prescribed.
This is wasteful of your time and may have a negative impact on your care. In addition, the effect of step therapy on efficiency in the doctor’s office is hideous. The resulting extensive paperwork, phone calls, and other wasted time burdens our health care system and handcuffs our medical providers as they try to overcome multiple burdensome layers of regulation to provide you with optimal health care. Now, under the new law, an insurer can make you try, and fail on, a different medication only once, before moving to the medication your doctor prescribed.
Third, the law now prevents insurers from requiring patients to take a medication the FDA has not approved for a specific medical condition. This is an especially welcome change. Your insurer should not be able to decide which medication patients should take, out of the chart they designed, after getting advice from professionals who may or may not have the proper training to make the decision.
In my career in treating chronic pain, the majority of older, generic medications have long been used “off label” but have not been specifically or extensively tested for a given painful condition. Newer, brand name medications may also be used “off label” at the discretion of your doctor. But they’ve generally been tested more thoroughly.
While Vermont and our entire country decide how to make health care both more accessible and affordable, it is important to recognize the need for, and indeed to mandate, more transparency in this discussion.
We must return to a system where patients and their health care providers decide what is best for their care, without dozens of layers of bureaucratic obstruction. Only then will the system truly work well and health care costs be contained.
Vermont lawmakers saw the facts, and I commend them for protecting the rights of Vermont patients by doing the right thing. The winners of this new law are thousands of Vermonters eager to live productive and active lives.
Dr. Robert Giering is co-medical director of Taconic Spine in Manchester Center.