It happens all too often: A physician prescribes the most effective treatment, only to have the patient’s insurance provider refuse to cover it because of cost.
Most South Carolinians will have an opportunity this fall to make sure they don’t become victims of these short-sighted insurance policies.
The insurance “open enrollment” period, which usually lasts from now through December for most plans, is the only time of year when patients can easily choose the best health plan options and ensure that necessary treatments are covered.
Many healthy patients don’t realize that their health plan won’t cover their physician’s treatment plan until it is too late and they already need it.
I see this problem all too often as a specialist treating South Carolinians with fibromyalgia.
A chronic disorder that results in pain, fatigue and sleep disturbances, fibromyalgia is one of the syndromes likely to face insurer cost-containment policies.
Approximately 7-10 million Americans suffer from fibromyalgia, and I alone have treated about 6,000 South Carolinians with this disease.
I do battle with insurance companies almost daily to get them to cover treatments that will help my patients live their lives.
Insurers often require my patients to try and fail on up to five older — and less expensive — drugs before the pharmacist can fill my original prescription.
This process is often called “step therapy” or “fail-first” because patients must fail on cheaper treatments before they can have access to the FDA-approved, or more expensive, medication.
And even after patents “fail first” some insurers still encourage physicians to switch the prescribed medication to a cheaper — and often less effective — alternative.
This can include forcing physicians and patients to experiment with the combination of two cheaper generic drugs, adjusting and re-adjusting doses in an effort to accomplish what one more expensive treatment could accomplish. In the case of fibromyalgia and other chronic disorders, finding the most effective course of treatment is a complex and delicate process.
The best treatment plan can vary from patient to patient, but I can tell you that cost-cutting insurer policies frequently prolong disease symptoms.
Insurance barriers mean that patients suffering from pain — fibromyalgia, rheumatoid arthritis, lupus, and diabetic neuropathy, among many others — can unnecessarily go for weeks or months without treatments they desperately need.
And for a person suffering the effects of a chronic illness, even one day without treatment is too long.
The lesson: Even if you have had no difficulty getting insurance providers to cover doctor-recommended treatments, you should closely review your insurance plan during this open enrollment period. Health issues can hit without warning.
When reviewing your policy, watch out for fail-first or step therapy policies.
If they are part of your health plan and you don’t make changes during open enrollment, it can mean falling victim to cost-cutting policies that severely limit the care you receive.
Use this open enrollment period to make sure your health plan makes sense for you.
Take the time to verify that your health care decisions are left up you and your doctor — not commercial interests.
Dr. Carlysle Barfield
Roper St. Francis Healthcare
Dr. Barfield, who has been practicing medicine in the Charleston area for more than 35 years, is a member of the American College of Rheumatology.