Opinion: Fail First? Is This Any Way to Practice Medicine?

(Aug. 16) -- Louisiana has become the most recent state to take action against a little understood abuse of the health care system that has been causing unnecessary suffering for patients for far too long.

Recently, Gov. Bobby Jindal signed a new law protecting patients from the "fail first" approach to prescribing drugs. This is an approach widely used by health insurance carriers and pharmacy benefits managers that forces patients to go without the drug their doctor has prescribed and use a cheaper drug.

If the less costly alternative drug fails to help the patient, the next step required by the insurance carrier is usually another substitute drug, always a cheaper one than the drug prescribed by the patient's doctor. After failing to get results with two substitute drugs, the third step might be approval of the drug originally prescribed.

The fail first system, or "step therapy" as the insurance industry prefers to call it, should not be confused with the practice of substituting less expensive generic drugs, which in theory are identical versions of more expensive brand-name drugs. In a fail first situation, patients are forced to accept a totally different drug, not a generic version of what their doctors prescribed.

Like any other physician, I am not infallible, but when I prescribe for patients, my priority is to relieve their suffering and speed their recovery. By contrast, the anonymous administrators of fail first systems have never met, much less examined, the patients whose drug options they are dictating.

The unnecessary suffering and in some cases outright health risks imposed by forcing patients to try and fail with less expensive drugs is not a concern for insurance companies. The overwhelming priority of the fail first approach is maximizing profits.

This attitude was starkly summed up by a quote from the head of one of the country's biggest pharmacy benefit manager companies. In a recent article published by the St. Louis Post-Dispatch, Express Scripts CEO George Paz said, "Our whole model is switching people to lower cost drugs. The more money my shareholders make, the more money I make."

While focused on their bottom line, the insurance industry is turning a blind eye to the tens of thousands of suffering patients, like Cynthia Toussaint of California, who can't access the medicines their doctors prescribed. Afflicted with severe chronic pain syndrome that attacked her vocal cords, Toussaint became a victim of fail first when her insurance company refused to continue paying for the pain and anxiety drug prescribed by her doctor and insisted she try a cheaper substitute.

This led to a recurrence of uncontrollable pain and hallucinations, relieved only when her doctor won a battle to restore coverage for her original prescription. It's a battle her doctor has to re-fight every three months, and this experience has led Toussaint to organize a campaign for an anti-fail first law in California.

Beyond personal horror stories like Toussaint's, it makes sense to lower health care costs by using the least expensive but proven effective drugs. Responsible experimentation is often necessary to find the most effective drug for a given patient. If two drugs are equally effective, most doctors will go with the more cost-effective option. But that decision must be made by a patient's doctor.

The idea that patients have to suffer and suffer before they get the care their doctor says they need is a concept most Americans find unacceptable. Unfortunately, it is the idea at the center of fail first programs.

David Charles, M.D., is vice chairman of the department of neurology at the Vanderbilt University School of Medicine in Nashville and chairman of the nationwide Alliance for Patient Access.