By Roseannette Lopez
Our health care system is among the best in the world. It has kept my fifteen-year-old son alive (I’m not giving his name to protect his privacy). He has hemophilia, a disease he was born with. Hemophilia is a blood disease where the blood does not clot normally. To stay alive, you need medicine. Without it, you will die. Even with it, the disease causes chronic pain and internal bleeding, making normal life difficult. You must find the right medicine to lead even close to a normal life.
However, finding the right medicine to treat hemophiliacs is not always easy, as each case is different. And while the right medicine is available for my son, that medicine is not always easy for patients to get. The problem is something called Step Therapy. It’s where the insurance companies require you to try one, or several, medicines first before they will approve the one that works. It makes you take several “steps” before you get the medicine you want, and the medicine your doctor wants.
Patients are forced to go through painful failures on medicines not prescribed by their doctors just so the insurance companies can save money. Think about it. You arrive at the pharmacist to get the proper medicine prescribed by your doctor, and the pharmacist tells you you can’t have it because the insurance company wants to you fail first on another medicine. That’s why step therapy is also called “fail first.”
My son has been required to “fail first” by taking a plasma-based drug therapy before he can get the right drug. He has to insert a large needle into his arm every day. He has developed a hip bleed and he is showing signs of new arthritis. In addition, the medicine he is forced to take has not been as effective in treating the hemophilia. My son is not a human guinea pig. He should not be forced into a painful therapy with awful side effects because the insurance company wants us to “fail first.”
And if you are wondering if this is common, 69% of health plans in the U.S. use Step Therapy, meaning it could change your life if you ever need life-saving or life-enhancing drug treatment for such diseases as Alzheimer’s, cancer, diabetes, epilepsy, or many others.
I have asked the insurance company to allow for my son to get the right drug therapy. It would allow him better results for the hemophilia and fewer side effects. We sent in a request to the insurance company and then we started getting denial letters. The denials came because of the additional costs.
However, studies have shown that when patients are forced to fail first, the process ends up costing more in the long run because of the side effects and hospitalizations. It just doesn’t make sense to force patients to suffer because the insurance companies are being penny-wise, pound-foolish.
The process called Step Therapy leaves my son, and patients around the country, vulnerable and unprotected. It’s not right to do that to human beings who just want to get well and live a productive life, like my son.
In many states across the county, laws have taken effect to stop therapy or take measures to ease the ill effects on patients. Texas has such a law, as well as California, New York, Connecticut, Louisiana, and many others. It may be time for New Mexico to consider protecting its people from the health care failures called Step Therapy.
Roseannette Lopez is the mother of a 15-year-old boy with hemophilia. She lives in Albuquerque, NM.