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opinion | Evan Hempel

‘Fail first’ fails patients

By forcing the sick to experiment with less expensive — and often less effective — drugs, insurers put profits ahead of health care

Christopher serra for the Boston Globe

‘I’m sorry,” said the help-line operator for my health-insurance company. “You need to try another drug.” She went on to offer a list of cheaper alternatives to the anti-depressant I’d been taking successfully for three months. Then chirpily suggested I could always just pay out-of-pocket. After three infuriating days of similar phone calls, I dropped my head to the desk and cried.

Since the last refill, my medication had been added to the “prior authorization” list for my insurer. Under prior approval, a patient must try a number of cheaper drugs to ensure they aren’t as effective before the insurer will pay for certain prescriptions. Such policies — also known as “step therapy” or “fail-first” — are a relatively new trend in health care, but their popularity is growing.

But in the name of cost-savings, insurance companies are second-guessing the treatment decisions of doctors working directly with patients — and most likely, putting those patients at risk for serious health consequences.

At first, I was told the prior approval process would take a minimum of two weeks. I had five pills left. We started the paperwork, and I kept calling. A supervisor told me there was a two-day expedited option, but I probably wouldn’t get my physician, who’d so far been very helpful, to cooperate. I had two pills left.

It’s been a tough year: After a bad break-up and subsequent move back home, it was no surprise my lifelong struggle with depression came to the surface a few months ago. As a transgender man, I’m not unfamiliar with worrying about roadblocks to the health care I need.


But dealing with this try-and-see approach isn’t unique to me — anyone coping with depression knows how hard it is to find the right treatment. By the time you get to the doctor, you’ve exhausted every non-medication effort — and yourself — leaving behind a singular and humbling desperation.

With a doctor’s support and counseling, you work your way through the long list of potential medications, considering the balance between side effects and potential benefit. Together, you pick one to try first, then another, then another.

Try a drug for a few months that helps a little but makes you too groggy to do your job consistently — fail.


Try a drug that maybe helps, but, although your house is spotless and you’re flying through to-do lists, you’re irritable and can’t focus. You try half the dose for another month, to no avail — fail.

Try a drug that makes your head feel like a balloon and kills your sex drive, though, rather pleasantly, makes you feel nothing — no joy, no sadness, no nothing. That one you consider.

But then your doctor painstakingly convinces you that better is possible, so you move on, eventually finding that miracle anti-depressant for your chemistry at last. The dizziness subsides, and you wake up one morning thinking, maybe today won’t be so bad. Success, at last. You start to rebuild your life.

Now, an insurance operator, who is not even a clinician, was telling me that trying four drugs — six months’ worth of side effects and debilitating depression — wasn’t enough to warrant such an expensive, if effective drug. Not anymore anyway.

Essentially, my insurer’s push for prior authorization would cost me at least two months of physiologically stressful drug transitions and side effects and slide-back in the recovery process to prove that something cheaper wouldn’t work. Or I could pay on my own indefinitely, a price tag that roughly equaled my monthly insurance premiums but that wouldn’t count toward my deductible. I had one pill left. Yes, I cried.

The next morning, a prescription bottle, free of charge, arrived via overnight delivery with a note from my physician’s office saying, “We’ll work it out.” Later, my doctor called to say he’d been able to use remotely related drug allergies and a family history of seizures to convince my insurer to authorize my medication for one year.


Several states have passed or are now considering bans on prior authorization, including a stalled bill in the Massachusetts legislature. It is the least that can be done for patients’ well-being.

I feel lucky. From working in the health care industry, I had a sense of how the system works. What if I hadn’t had a supportive doctor? What if my job prevented me from making endless phone calls during business hours? What if I hadn’t felt entitled to asking to speak to a supervisor? What if I didn’t speak English well? I am young, white, and relatively healthy. Even with all these advantages, I barely escaped a bureaucratically enforced backslide to a depression wreaking havoc on my life.

Health care costs are out of control. But jeopardizing patients’ health is too high a price to pay for savings, particularly when insurance companies are still turning profits on our premiums.

Evan Hempel works in clinical research and lives in Somerville.