Let doctors decide care, not insurance bureaucrats

As executive director of the American Autoimmune Related Diseases Association based in Eastpointe, I hear many heartbreaking stories from patients who have difficulty dealing with autoimmune illness while experiencing the stress of finding medical care. One patient’s experience was so appalling that I knew our association had to get involved.

Heather, a young woman in Michigan, received a devastating diagnosis of multiple sclerosis. During this difficult time, she also encountered an additional obstacle: accessing prescribed treatment to control her disease.

When Heather’s doctor prescribed a new, expensive oral treatment, her insurance company denied the prescription in favor of “step therapy,” a health insurance policy seen as a cost-containment strategy. This practice requires the patient to first try older, less expensive therapies before the insurer agrees to cover the doctor’s prescribed treatment. Because of step therapy, Heather was assigned an injectable drug, which she tried for six weeks. The drug works for many but was inappropriate for her.

Over the following months, Heather’s insurance company continued to require her to try drugs that, according to available evidence, likely wouldn’t be effective for her. She talked to her doctor weekly and eventually obtained a new prescription for the original oral treatment. Even then, her insurer required extensive efforts on the part of Heather and her doctor to approve the treatment, including blood tests, imaging scans, and phone calls from the doctor.

This process consumed a great deal of Heather’s time as she acquired “a notebook full of names and information” of insurance company contacts. She missed six months of work, including a period when there was opportunity to earn significant overtime pay and her company had to hire someone to assume her responsibilities.

The result of all these delays was that it was five months between Heather’s diagnosis and the initiation of the proper treatment, despite doctor recommendations to start therapy as soon as possible after diagnosis. This has permanently impacted her health and mobility.

Heather’s story illustrates the concerns many have with step therapy. While all sectors of health care seek ways to reduce spending, it will be essential to implement policies that improve patient outcomes without causing harm.

Intruding on the doctor-patient relationship or denying patients necessary treatments will ultimately prove counterproductive and often result in added medical expenses in the future. That’s why my association has initiated a campaign, “Let MI Doctors Decide,” to arm patients and doctors with the knowledge and resources to navigate step therapy and secure the right treatment at the right time.

To learn more about this issue and obtain information for how to submit an appeal when faced with step therapy, visit www.letmidoctorsdecide.org or call (586) 776-3900. We must work to advocate for all patients being affected by insurance policies that not only burden the patient and the doctor but also jeopardize the patient’s health.

This article originally appeared in The Times Herald.