My Turn: Brittany Ricci: Insurance algorithms shouldn’t dictate treatment

Imagine a system in which a patient gets the right medication for their chronic illness the first time around: the medication their doctor is confident will be effective and the patient feels most comfortable taking. I have witnessed firsthand that, for certain diseases, this is not how the healthcare system currently operates.

That's why I'm speaking out to urge Rhode Island lawmakers to pass legislation that will help ensure that patients and their healthcare providers have the final say in medication treatment plans.

I was diagnosed with ulcerative colitis my freshman year at Providence College -- not the most ideal disease to be dealing with while sharing a bathroom with 30 girls I was meeting for the first time. For years, my UC smoldered. I was on medications in combination with steroids that, for the most part, worked. I was even briefly in remission during this time.

But, about three years ago, right before the beginning of medical school, my symptoms began to present themselves again and this time even more aggressively. I had developed a pocket of infection near my colon, and, after another colonoscopy, my diagnosis was changed to Crohn's disease. It was painful to stand, to sit, to walk, and my medical team decided we needed to be more aggressive with our treatment plan. The medications I had been on up to this point are simply not effective for the type of Crohn's I have.

However, after settling on a new medication regimen, I got a call from my gastroenterologist saying that my insurance company denied the request to start the recommended treatment. I was told I would have to "fail" on treatment with another medication as dictated by my insurance company before I could start on what my doctor had recommended. I was honestly a bit shocked to hear this. I knew insurance companies could deny medications, but this case seemed pretty straightforward to me. There was clear scientific evidence to back this treatment over other medications. Wasn't that enough?

This process is known as step therapy -- and it needs to be reined in. As a medical student, I understand the role that cost plays in our medical system. But, as a patient and future doctor, I cannot stand by and let insurance companies and pharmacy benefits managers dictate treatment plans that are less effective for patients.

S0772/H5806 have been introduced in the Rhode Island General Assembly to put common sense provisions in place when step therapy is applied to a patient. Just this week, it passed the state Senate 36-0. When passed, a patient will no longer be forced to fail an alternative medication if they are stable on a medication, even if the patient's insurer changes, and clinicians will have the final say regarding which treatment is medically necessary for a patient. Reasonable time frames will also be put in place so that patients don't face an endless wait for answers all while their disease continues to progress.

Because this type of legislation was not in place when my request to start a particular medication was denied, I was left with no choice but to take the medication as dictated by the treatment algorithm used by my insurer.

That algorithm ended up being very bad math both for my health and overall healthcare costs. Though I eventually got the medication that was initially recommended to me after about a year, I had numerous trips to the hospital, three surgeries and other complications.

Today, I am doing much better but still dealing with the repercussions of the damage step therapy caused. I can't help but ask -- was all this suffering really necessary for me to get access to a medication that was recommended to me months earlier?

We will all be patients at some point, and that's why I'm asking lawmakers in Rhode Island to pass S0772/H5806, which will help put control back into the hands of the patient and the provider when it comes to deciding on a treatment plan. This bill is a step in the right direction toward creating a truly patient-centered system that encourages the practice of evidence-based medicine.

At the end of the day isn't that what we all expect when we seek medical care? For the role of doctor to be filled by the doctor -- not a treatment algorithm.

Brittany Ricci is a student at Brown University's Alpert Medical School.

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