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Insurers win, patients lose with step therapy

Israel
Israel

I’ve spent much of the last year in constant pain – all because my health insurance company decided it wouldn’t cover the medication that my doctor prescribed to treat my chronic rheumatoid arthritis.

I was diagnosed early last year after collapsing at work. My doctor prescribed a biologic infusion treatment, but my health insurer required me to first fail on six other drugs before I could gain access to the biologic.

It’s taken me more than a year to go through this so-called “step therapy” process as I tried, and failed, on each insurance-mandated treatment. During that time my rheumatoid arthritis progressed so much that I lost my job, can no longer drive or care for my son by myself, and need help with simple tasks like taking a bath. The medications my insurance company required me to try also came with their own side effects, including dangerously high blood pressure, eyesight issues, nausea and hair loss. I’ve been hospitalized and had several emergency room visits.

A few months ago, after my doctor provided proof that the last insurer-mandated medication did nothing to help me, I finally received treatment my doctor originally prescribed. And while the new therapy is starting to work, I can’t help but think about what I’ve already lost: precious time with my son, my independence, my career and so much more.

Step therapy protocols are entirely based on cost. There is no medical justification for them, and often there is no clear or quick way for physicians to appeal and stop the insurance company from making a patient try and fail on other drugs first. It’s also significant to note that health insurers often mandate step therapy not only for people living with arthritis, but also for those battling cancer, multiple sclerosis, diabetes and a range of other conditions.

So now I’m fighting back – not only against my rheumatoid arthritis but against the policies that have hurt me and my family. I’m asking state lawmakers to act on a proposal that will help protect North Carolinians like me.

Fortunately, the General Assembly just formed a committee to consider establishing a clear process for health care providers to request exceptions to step-therapy protocols. Most importantly, the proposal would require insurers to make exceptions when a physician determines that the insurer-required drug is not in the best interest of the patient.

Like many North Carolinians, I will battle my chronic condition of rheumatoid arthritis for the rest of my life. But I shouldn’t have to fight with my health insurer to obtain a treatment that works. We need doctors, not insurance companies, to decide what’s best.

Arloishia Israel is a member of the Arthritis Foundation. She lives in Matthews.

Correction

A Forum letter in Monday’s Observer misidentifed the candidate challenging Gov. Pat McCrory in the Republican primary. He is is former state Rep. Robert Brawley of Mooresville.

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