Step Therapy Reality Check

WBZ’s I-Team recently broadcast a story of a 22-year-old college student’s experience with medical insurance that should be a cautionary tale for all. Reading Eitan Kling-Levine’s story and the subsequent price he paid with his personal health should shock you.

And in case you think this would never happen to you, let me share a personal experience with “step therapy”, albeit one with lesser consequences and a happier ending.

Several years ago, I was diagnosed with mild to moderate obstructive sleep apnea. Not only a relational inconvenience as the snoring kept my partner awake, it was a source of concern as I was continually exhausted from interrupted sleep. The standard protocol for this would be a CPAP, something I had familiarity with as my Dad had COPD and had attempted to use one.

Now I, the patient, know myself fairly well and, as an extremely light sleeper on a “good” day, I knew the noise of the CPAP would keep me awake as much as the sleep apnea did. And then there are the usual side-effects. So I did quite a bit of research and discovered that in my case a dental device called a mandibular advancement device (MAD), fashioned by a dentist with sleep apnea expertise, would be a more effective solution. And, to my great amazement, a renowned expert in this therapy had a practice in Worcester, MA – 40 minutes away. So I set about getting approvals and referrals.

My primary care doctor and the neurologist in that network, all submitted their paperwork. Everything was proceeding smoothly until a pinhead at the insurance company intervened and rejected the referrals. As I had not “failed” with a CPAP  (a $2,000-$3,000 expense), I was not approved for the MAD device ($1,400). In other words, I was not allowed the use of a less costly, more appropriate therapy unless I stepped through the CPAP therapy and failed.  Does that make any sense?

In the end, through the advocacy of a very skilled and persistent referral department in my health care provider’s practice, the MAD device was eventually approved. It took over 6 months; that was 6 months of loss of sleep, anxiety over a load of paperwork and frustration that a solution to a health problem was put on hold by an insurance company.  It could have been worse as you learn from reading Eitan Kling-Levine’s story.

Step Therapy is bad for the health of people, good for the health of someone’s bottom line. From what I can read, the Massachusetts bill correcting this insanity has been referred to committee.

Hopefully that isn’t “step therapy” for killing the measure.

 

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