California bill would limit 'step therapy' in pain treatment

July 01--Radene Cook was an airborne reporter for a radio network when she survived a harrowing plane accident in Los Angeles in 2000.

The initial pain she suffered became far worse, she said, after her insurer required her to take Tylenol 4 and undergo months of steroid shots before it would pay for another course of treatment her doctor thought best.

"They wanted me to 'fail' the shots first," Cook said. "And there was no timeline given for how long this would have to go on."

Cook's bitterness -- the shots inflicted permanent damage, she says -- has led her to urge passage of a proposed California law to limit the practice known as "step therapy," or "fail first," in insurance coverage of pain treatment.

"I'm a Libertarian, but I feel this law is necessary to protect people," Cook said. "At one point, the insurer even told me, 'You either take the shots and the Tylenol, or you get nothing.' "

Assembly Bill 1826 by Democrat Jared Huffman of San Rafael passed the Assembly on a party-line vote, with Democrats in favor and Republicans against, and is pending in the Senate.

The bill would prohibit insurers from requiring that patients first try over-the-counter or other prescription drugs before covering pain treatment that a patient's doctor prescribes.

Some patients are forced to try up to five treatments that fail to work -- and get involved in prolonged appeals processes -- before their doctors' original pain prescription will be covered, bill supporters say.

Insurance interests are lobbying state senators to reject Huffman's proposal, arguing that prohibiting step therapy will increase premiums and drive up drug costs.

In letters, insurance associations and companies also contend that step therapy is a good idea because employees of health plans are often in a better position than patients' doctors to know the risks of drug interaction.

Blue Shield of California also wrote that "step-therapy protocols also act as a check-and-balance to the cozy relationship that exists between many physicians and drug companies."

The California Association of Health Plans wrote: "Sometimes patients are harmed by an error in the prescription or in the use of a medication."

The group's letter says plans consult "expert opinion" and federal research, while many doctors lack a procedure to get "the latest information" about proper drug dosages.

Huffman's bill doesn't prohibit insurers from requiring that patients try generic drugs instead of more expensive brand-name versions.

Dr. Scott Fishman, chief of pain medicine at the University of California, Davis, Health System, called the insurance interests' claims "disingenuous."

"They don't pass the smell test," he said. "I think it's a slippery slope to leave this (decisions about pain drugs) to insurance companies, which have a conflict of interest."

Treatment costs are actually driven up when patients have to keep trying medications, Fishman said, because patients make more trips to emergency rooms, and need more tests and visits with doctors.

In a letter to legislators, Dr. Lee Snook, a Sacramento pain specialist, wrote: "We have had patients commit suicide while awaiting authorizations for treatment and medications" or when medications have been "abruptly stopped."

Patrick Johnston, president of the California Association of Health Plans and a former legislator, said, "Any individual (patient) story may have merit, but when you interview that person you only get that side of the story.

"More mandates reduce flexibility and induce high costs," he said. Insurers, he said, also have concerns about preventing addiction.

New Jersey is the only state that prohibits "fail first" procedures in pain treatment. Other states have debated it.

The American Chronic Pain Association, California Medical Association, and a number of labor unions support the bill.

"This came to me from a nonprofit group of pain sufferers. You can't get more grassroots that that," said Huffman.

The bill's sponsor is For Grace, a Los Angeles nonprofit that was founded by former ballet dancer Cynthia Toussaint, who suffers from chronic pain.

"To me this bill is about one thing," Toussaint said. "Suffering."

She said she suffered an injury 28 years ago that was so affected by misdiagnosis -- and failed treatment that her insurer required -- that she ended up bedridden and unable to speak for five years.

When she was finally given a drug that provided relief, her insurer subsequently decided that she had to try something else that cost less. Toussaint said she spent weeks doubled over in pain, and her recovery was set back.

She is still fighting regular attempts to get her to switch treatment, she said.

"That sacred relationship between doctor and patient is not there with 'fail first,' " Toussaint said, "The reason why 'fail first' is so haunting for people with chronic pain is because we know what works right away."

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Call Susan Ferriss, Bee Capitol Bureau, (916) 321-1267.

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