Friday April 26, 2013

I know firsthand what it's like to live with chronic pain. It's difficult sometimes to walk, write, or to do a myriad of other daily mundane chores. Living with it constantly is a burden I wouldn't wish on anyone.

But while this country -- and the state of Vermont -- tackles affordability and accessibility of health care for all patients we must not forget the barriers to access that don't make headlines every day. In fact, many patients don't even know the hoops they're forced to jump through by insurance companies every day.

Whether you have arthritis, multiple sclerosis, cancer or some other debilitating disease, there's one thing that's important: The expertise of your healthcare provider. It's your doctor who knows you and your condition the best. But imagine someone making a medical decision for you who is not your health care provider and has never even seen you. That's exactly what's happening in Vermont and across this country: Health insurance companies are preventing patients from getting the medicine their doctor prescribed.

It's known as "step therapy," and it's when the insurer refuses to pay for the medication the health care provider prescribes until the patient first tries, and fails several times, on other medications -- with no regard for the health care provider's judgment and expertise, and no regard for the patient, who is made to suffer longer.


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Another way of delaying access to much-needed medication is by forcing patients to take drugs that are not FDA-approved for their specific condition. Known as "off label" prescribing, such a practice sounds dangerous, and it is.

These insurer practices result in higher profits for insurance companies and patients having to endure senseless suffering at the hands of an insurance company blocking access to the health care prescribed by a physician.

Unfortunately, the trend of step therapy as an insurance abuse is on the rise. According to the Pharmacy Benefit Management Institute, in 2012, about 65 percent of employer plans used these fail first requirements to control costs of pharmaceuticals, compared with 50 percent just two years earlier.

Stalling tactics like these insurer practices result in more trips to the health care provider, more trips to the hospital, and higher healthcare costs.

Now, an important bill is making its way through the Legislature in an attempt to limit these insurer practices, and to ensure patients have access to the medication their health care provider prescribed. S. 147, introduced by Senator Kevin Mullin, would prohibit anyone other than a healthcare professional from assigning a patient medication that's off-label. The bill would also prevent a patient from having to fail more than once on the same medication before an insurance company would pay for the medication originally prescribed by the physician.

It comes down to one very important question: Who's best qualified to treat a patient, a doctor or an insurer? I know my answer. Putting that decision in the hands of my insurance company is not a risk I'm willing to take.

It's critical that lawmakers pass S. 147 to preserve the provider-patient decision-making process. It's the right thing to do for the patient and the right thing to do to keep healthcare costs down. As both a patient and an advocate, I know firsthand how important that is.

Linda Martin is a resident of Brattleboro living with chronic pain.