Doctor's guest opinion on the "Fail First" policy

Discussion in 'Fibromyalgia Main Forum' started by Missizzy, Oct 5, 2008.

  1. Missizzy

    Missizzy New Member

    Hi all--I noticed this fine opinion piece today in the Medford, OR Mail Tribune of October 5th. Dr. Greene is a local doctor. I have no experience with him but I do find his commentary timely. For those searching for a doctor in Southern Oregon, he might be worth a try. I admire him greatly for speaking up on this issue.


    Insurers' 'fail first' policies serve no one

    By By Rudy Greene, M.D.
    October 05, 2008 6:00 AM
    We've all heard that Oregon has more than half a million uninsured residents. We also know that barriers to access to medical care exist not only in the uninsured but often in the underserved, poor and disabled populations and those who live in rural areas without adequate medical services. And barriers to access also hit those who cannot advocate for themselves.

    But even Oregonians who have adequate insurance coverage and can obtain medical care face another bear of a barrier. That barrier to treatment is the insurance company.

    My fellow physicians and I are increasingly frustrated at the undermining of our judgment, diagnosis and/or prescriptive treatment. Daily, we grow more worried as we watch insurance company employees play doctor.

    This past month, the Oregon Board of Pharmacy considered this very issue.

    Consider the scenario of a typical patient who has fibromyalgia. As a patient who is insured by a major health insurer, she visits her doctor on multiple occasions with specific and nonspecific symptoms.

    After ruling out several possibilities, her physician diagnoses her with fibromyalgia and prescribes a targeted therapy, one of two FDA-approved drugs to treat fibromyalgia. The insurer denies coverage for the prescription and mandates that the patient must "fail first" at other less expensive, non-targeted, non-FDA approved therapies.

    The patient tries several of these therapies and they fail. Each time, she must wait several weeks or months to get an appointment with her doctor to alleviate her symptoms. The cycle continues for several months until the patient is finally allowed access and coverage to the approved, targeted medicine she should have received initially.

    Who's saving money in this scenario? Not the physician, who pays his staff overtime to spend hours on the phone and to fill out forms to obtain approval from the insurance company. The patient hasn't saved money. She missed work during this time, contributing to her frustration.

    Nobody wins in this "fail first" scenario. Health costs go up. The wrong parties make health decisions. Physicians' hands are tied when it comes to the best treatment course for the patient, ultimately compromising the standard of care. The patient suffers needlessly every time care is compromised.

    Additionally, insurers often put into play other types of restrictive policies that block access to most appropriate care. Examples include gate-keeping and pre-authorization.

    As a physician provider, I am deeply concerned over any and all access-to-care barriers as they affect the ability of a patient to obtain compassionate, effective, targeted, affordable, high-quality and high-value health care. Inappropriate medication switching by insurers compromises these values.

    Access to medications cannot and should not be denied, especially when they may preserve quality of life and the ability of patients to be productive members of society. Ironically, not only may the appropriate medications be life-saving but may actually be cost-effective by keeping these patients in the work force and/or cutting their need for further medical care.

    Dr. Rudy Greene of Talent, OR is a rheumatology physician who treats fibromyalgia patients.

  2. PainPainGoAway

    PainPainGoAway New Member

    This is so true! I'm thrilled to see a positive response from a doctor regarding Fibromyalgia.

    There are many doctors out there just as frustrated and would like to be able to help us get the right meds and treatment.