Californians are forced to remain in pain by their insurance companies

Pain is something that most Americans suffer from, whether it is specified to certain body sites or pain related diseases and conditions.  In fact, approximately 76.2 million Americans currently suffer from pain, which is more than diabetes, heart disease and cancer combined.  Why is it then, so many pain patients are forced to continue suffering by their health care providers or insurers?  

The answer lies in a practice called “step therapy” or “fail first,” which is being used by providers or insurers to help control healthcare costs, while using patients as guinea pigs.  Pain patients are obligated by their health care providers or insurers to experiment with different medications or treatments before receiving the one deemed best by their health care provider.  Some patients are required to try up to five alternative treatments before they are allowed to use the correct one.  Additionally, health plans often force off-label prescriptions; essentially requiring patients to use treatments and medications that have not been FDA-approved for their specific condition.  As such practices are becoming quite normal, it is important that Americans know it could be happening to them, as most are in the dark about the issue.

It is for this reason that Assembly Bill 1144 has been created and introduced into legislation.  This Bill would prohibit health plans and insurers from requiring a patient to use a different pain medication than the one prescribed by their physician.  AB 1144 will put an end to patients in California being forced to endure weeks, months or even years of unnecessary pain and inappropriate treatments.  The Bill would also prevent patients who have changed insurers from having to repeat the “step therapy” process if they have already gone through it with their previous insurer.

An article titled “A Bitter Pill” was published in the March issue of Southern California Physician Magazine, which examines “step therapy” or “fail-first” practices by health care providers or insurers and identifies the burdens physicians face when prescribing medication.  The article illustrates how such practices by health care insurers hinder a doctor’s drug choice.  It is explained that “drug insurers structure their coverage to provide cost-effective treatment for broadest cross-section coverage of patients, but it’s when a patient deviates from the average that drug insurers most often seem to interfere.”  Patients are then required to try various cheaper drugs before being allowed to use the one prescribed by their physician, without accounting for an individual’s reaction to different drugs.  A patient’s doctor understand their medical history and has the ability to prescribe what medication or treatment is best fit for each individual; unless of course their choice is challenged by health care insurers or providers.

AB 1144 would also prevent the issue of off-label prescriptions.  Insurers sometimes obligate doctors to prescribe drugs that have been FDA-approved, but not approved for a specific condition.  The example given in Southern California Physician Magazine explains that with fibromyalgia being a difficult condition to treat, “insurers contracting with Medicare Part D required patients to fail off-label therapy on gabapentin before beginning on-label treatment with more-expensive Lyrica.”  Both medications have been FDA-approved, but Lyrica is the only medication of the two to be FDA-approved to treat Fibromyalgia.

While American’s continue to suffer, chronic pain is estimated to cost the United States $100 billion annually, which includes healthcare expenses, lost income and lost productivity due to suffering.  This cost is only being driven up by health care bureaucracies each and every time a patient fails on an un-approved treatment and they are forced to return to their physician for further medical assistance.  Adults alone have an average of 11 million physician office visits annually with a diagnosis of joint pain, over 1.1 million outpatient hospital visits, about 1.5 million emergency department visits and over 177,000 inpatient hospitalizations.  With this amount of suffering, it is time something be done to take action.  It is wrong for health care insurers and providers to keep their patients in agony.  Patients are not to be used for experimental purposes and should not have to experience prolonged suffering.

Want to see more stories like this? Sign up for The Roundup, the free daily newsletter about California politics from the editors of Capitol Weekly. Stay up to date on the news you need to know.

Sign up below, then look for a confirmation email in your inbox.


Support for Capitol Weekly is Provided by: