March 25, 2019
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If a doctor prescribes a medication, a patient shouldn’t have to try others first

George Danby | BDN
George Danby | BDN

Finding health insurance that works for you can be a tedious and often confusing process as you look for a plan that covers your needs. When you find one, relief is probably the first feeling.

But for Mainers living with serious diseases such as multiple sclerosis, cancer or arthritis or managing mental health issues, finding the right plan and the right treatment regimen is critical. Having consistent access to the medicines that can help control and manage chronic, serious illness and disease may be the thing that allows them to engage and participate in their lives and our communities.

I’ve heard from a lot of my constituents about a practice by insurers that can be a barrier to that access. It’s called “fail first” or “ step therapy.” It’s when a doctor prescribes a certain medication for the patient, only to have the insurer force the patient to try other medications first and have it fail on them before agreeing to cover the medication the doctor wanted in the first place. It undermines the doctor’s expert opinion and causes needless suffering for patients.

In many instances the patient is required to step through as many as three or four different medications before receiving the medication their doctor deemed was best for them. And for some, they are asked to repeat this process every time their insurance renews. It is a practice that has grown in use among commercial health plans in the past decade.

Insurers say they do this to save money. While reducing health care costs is an important goal, we can do it in a more humane, patient-centered and effective way. Ensuring patients receive the right medicine at the right time can be the best thing for patients and actually save money within the overall healthcare system by reducing serious complications including costly hospitalizations, emergency room visits and additional care.

That’s why I’m sponsoring a bill that would reform the way step therapy is used in Maine. LD 1009, “An Act To Provide Protections for Maine Patients Facing Step Therapy,” would ensure a fair and timely process for exemption from the practice if a patient’s case warrants.

The legislation does not prohibit the use of step therapy, but it creates an expedited time frame for all requests and appeals — 48 hours for non-emergency circumstances and 24 hours for emergency cases. This will eliminate potentially months of needless suffering by the patient and costly return medical visits.

The bill also provides a mechanism by which the doctor can override step therapy when it’s medically appropriate for the patient. After all, the healthcare provider, in consultation with her patient, best knows the patient’s medical history and can best assess whether they’ll have a bad reaction to starting a new medicine or interrupting an existing one. It’s the doctor who knows what treatment will have the best chance of success.

This is common sense legislation -– and it is an idea that I and my colleagues overwhelmingly supported in 2015 and 2018 with similar bills. Unfortunately, in both instances, we failed to override the veto from Gov. Paul LePage. But it is my hope that this is the year we can get it over the finish line. Twenty-two states have already passed laws like this and others, like Maine, are looking to do so this year.

Delaying access to or interrupting appropriate therapies can have devastatingly debilitating consequences and can even be life-threatening. We need uniform policies in the state so that all patients receive the best treatment for their conditions. We’re all different. A one-size-fits-all paradigm isn’t appropriate.

This bill provides a layer of transparency and reassurance for the patient that is currently missing. It calls for basing decisions on clinical guidelines as a matter of public health and public interest.

It’s the right thing to do.

Charlotte Warren, D-Hallowell, is the representative for House District 84.



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