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Calling for End to Step-Therapy, Fail-First, and Special Tiers

  • Publish Date : 2011/10/15
  • Author : National Fibromyalgia & Chronic Pain Association

Synopsis: Strong potential for harmful effects to have step-therapy fail-first and special tiers in health care.

Main Document

National Fibromyalgia and Chronic Pain Association issues Position Paper Calling for End to Step-Therapy, Fail-First, and Special Tiers.

The National Fibromyalgia & Chronic Pain Association (NFMCPA) feels it is not in the best interests of patients, and additionally that there is strong potential for harmful effects, to have step-therapy, fail-first, and special tiers in health care. We urge necessary laws and policies be enacted to cease their continuance.

The National Fibromyalgia & Chronic Pain Association today issued a position paper that calls for an end to step-therapy or fail-first as insufficient treatment options which needlessly prolong the suffering of fibromyalgia and chronic pain patients.

The NFMCPA is the first nonprofit organization to issue a paper on this subject specifically addressing and advocating for the needs of the fibromyalgia and chronic pain patients.

Jan Chambers, president and founder of the NFMCPA, will be discussing more about this issue during the NFMCPA's newly launched bi-weekly online radio program on BlogTalkRadio. "Step-Therapy Fails for Fibromyalgia Patients" will air live on Friday, Oct. 14, at 9 a.m. MT. For additional details to hear the program, visit www.blogtalkradio.com/nfmcpa.

The position paper is detailed below:

National Fibromyalgia & Chronic Pain Association Position Paper on Access to Care for Step-Therapy, Fail-First, and Special Tiers Acute and chronic pain management is unique to each patient. It is not a repetitive process nor a technique applied for relief in the same manner from patient to patient for a similar beneficial outcome. Whereas removing an appendix, treating a strep throat or common medical occurrences can be effectively treated by a standardized process repeated with patients, a standardized process is inappropriate for patients with pain. Pain patients need direct interaction with a treating physician who is aware of patient history and current condition.

Disparities and increased vulnerability to pain are found in:

  • having English as a second language
  • race and ethnicity
  • income and education
  • sex and gender
  • age group
  • geographic location
  • military veterans
  • cognitive impairments
  • surgical patients
  • cancer patients, and
  • the end of life.

Turning a necessary interpersonal relationship between a patient and a physician into a process approved by a removed decision-making body through step-therapy, fail-first, and special tiers is not in the best interests of patients. Additionally, there is strong potential for harmful effects.

Pain can be a disease unto itself.

The Institute of Medicine's June 2011 Report, Relieving Pain in America, calls for "a recognition of the complexity of the pain experience." Most researchers and clinicians use the "bio-psychosocial model" for pain which recognizes the interrelation of biological, psychological, and social/family/cultural contexts of pain to understand and treat pain. Pain is part of a symptom cycle where inappropriately addressed pain decreases psychological wellbeing, disrupts essential sleep, increases anxiety, decreases the patient's resiliency and quality of life, and is linked to suicide. Inadequate pain management causes harm to patients.

Under step- and fail-first therapies, patients are required to fail on lower-cost medications and treatments before insurance companies will cover the cost of medications originally prescribed by physicians. Often these lower-cost medications include over-the-counter drugs that are insufficient treatment options. Step-therapy was instituted to minimize cost burdens; however, the practice has been shown to potentially produce the opposite effect. While pharmacy costs may go down under step-therapy, research indicates that overall medical expenses increase due to resulting increased inpatient and emergency room costs.

Using special tiers designed by insurance companies shifts the expense of medications to their insured by requiring them to pay a percentage of cost rather than a co-pay. This places access to front-line medications out of reach for most patients. Simply put, creating an insurmountable barrier to care is not an acceptable purpose of insurance.

Physical and emotional costs are associated with step-therapy, fail-first, and special tiers practices.

Patients who must fail first before receiving the appropriate care for their conditions are left to suffer for longer than necessary. A study on the effects of step-therapy for treatment of depression indicated that complications, such as drug resistance, recurrences, and chronicity resulted with each failed treatment. People who experience acute pain may go on to develop chronic, intractable pain. Step-therapy also increases the burden placed on physicians' time with the increased approvals they must complete.

The negative effects of step-therapy expand over a number of diseases and conditions. The Epilepsy Foundation asserts their position against step-therapy practices. They state that seizures can result in injury to the patient and others as well as cause lasting brain damage and should therefore be prevented if at all possible. Patients who must fail first on inadequate medications are at increased risk for seizures and their consequences.

Fibromyalgia patients are subject to severe chronic pain and numerous overlapping conditions. It is inappropriate to institute any policy that requires FM patients to needlessly suffer longer than necessary or that increases risk for complicating conditions.

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