Monday, August 16, 2010

"Fail First" Prescribing and Why It Does Not Work

Recent news stories have highlighted the practice of "fail first" or "step therapy" required under insurance companies' drug formularies. My father is a general practitioner and formerly an employee of the FDA- one of his particular interests is pharmacology. I've proven an interesting subject in this regard, because I have a lot of weird drug reactions, some of which might stem from a closed head injury when I was about four.

I cannot, for example, take any ephedra-based medications. This is problematic because I have chronic, debilitating environmental allergies. I am allergic to trees, grass, dust, mold...just about anything that might be making the air a little crunchier than normal. I don't respond to most over-the-counter allergy meds other than Benadryl, which everyone knows has the unfortunate side effect of sedation. I refused a hit of acid once in college because I can hallucinate quite nicely on something as ordinary as Sudafed.

Dad had an argument on the phone one day with some woman in India who kept telling him that Claritin and Clarinex are the same drug (they're not), because my insurer wanted to keep me on the cheaper, over-the-counter Claritin; believe me, if it worked, I'd take it, but I take the way more expensive Clarinex because it doesn't. Dad finally blew his cool and explained, as he had to me at my request, the chemical differences between the two drugs to the nice Indian lady. I was approved to continue on the more expensive Clarinex. I can just hear him, his anger rising, outlining the organic chemistry involved over the phone. He was still upset when I talked to him.

I also use Nasonex, a nasal steroid, which is, unlike Clarinex which is second-tier and $80 for three months' worth through mail-order, a third-tier drug. It's $120 every three months, if they approve you for it. Dad's still getting a few samples here and there, so I'm not switching back to one of the older inhalers until I'm forced. I can't afford the $120 for Nasonex, you see. I can't do without a nasal steriod, either. My insurance doesn't cover allergy testing and I haven't taken shots since I was about twenty-five- after having them twice a week from the time I was two until I rolled off of my parents' insurance in graduate school.

"Fail first" or "step therapy" is a classic case of insurers trying to dictate the practice of medicine to the people who actually practice it, something my father foreshadowed many years ago when a large HMO used to call during dinner to badger him about joining their network. He refused, his refusals growing louder and more colorful with each call. "Rationed care!" he'd bellow after he hung up, stalking through the house. "The &!*% insurance companies are going to force us into their version of socialized medicine! I didn't go to medical school to be told how to treat my patients by some idiot with a business degree!"

I haven't always gotten along with my father, to say the least. However, he's an outstanding, careful, and conscientious physician. I took those tirades very much to heart, little knowing that I'd be at the center of such battles over what seem to be simple allergy medications. My allergies, however, are so severe that they require very careful medication protocols; to my insurer, though, I'm just costing them too much money.

The point, I guess, is that insurance companies should leave the practice of medicine to medical professionals, and not second-guess their prescribing to the point that patients' health is endangered. I was in respiratory failure for nearly two years, and without Clarinex and Nasonex, I cannot breathe. I think that's sort of an important thing, don't you?

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