Bill aims to get most effective treatment to patients

In step therapy, insurers can force doctors to prescribe cheapest drug before best

Dr. Barbara McAneny says ordering a chemotherapy drug for a patient can sometimes feel like playing “Mother May I” with health insurance companies.

For example, one carrier did not want to pay for a certain medication and insisted on another variety. But the Albuquerque-based oncologist feared that drug would inflame her patient’s other medical conditions.

So goes the back-and-forth between doctors and insurance carriers.

But soon, patients could have an easier way around the strictures set on prescriptions by insurers.

The Legislature overwhelmingly approved a bill during its session this year that seeks to rein in the insurance company practice of requiring patients try a less expensive medication before using a costlier option, and usually only after the patient has failed on the cheaper drug.

Insurers argue the measures, known as step therapy or fail first treatment, are an important means of reining in spiraling drug costs and curbing the influence of drug manufacturers that market pharmaceuticals directly to patients and doctors.

But critics argue step therapy can in some cases cause patients to suffer on inadequate medications or regress and interferes with what doctors consider to be the best care for their patients, in turn putting money ahead of medicine.

“This will have the health plans make those decisions based on science,” said McAneny, president-elect of the American Medical Association.

A growing number of states have sought to curb step therapy, and while this legislation may not be the strictest such measure, patient advocates and doctors argue it is a step in the right direction.

Under Senate Bill 11, now sitting on the governor’s desk, insurers would have to base decisions about step therapy on the recommendations of experts.

And the bill would provide an avenue for patients and prescribers to quickly

get an exception from an insurer’s decision based on medical necessity.

Health insurance plans already allow for exceptions. But critics have argued that the current process can be lengthy.

Under SB 11, an insurance company would have to handle the request for an exemption within a matter of days. And if that is unsuccessful, patients would be able to appeal to the Office of the Superintendent of Insurance.

Gov. Susana Martinez has until March 7 to sign the bill or it will be automatically vetoed.

Step therapy has proliferated as prescription drug costs have risen.

McAnneny said doctors like her are open to measures that promote more economic use of lower-cost generic drugs. But more complicated or serious cases can require balancing numerous prescriptions against a patient’s particular needs, she said.

“This is not the way we should work to control drug pricing, which does need to be controlled,” McAneny argued.

In such cases, she said, medical professionals should not have to take patients off treatment they know is working or see the patient have to go through the step process again in the course of switching insurance plans.

“To take them backwards might take them from walking to a wheelchair,” said Sen. Liz Stefanics, a Democrat from Santa Fe and one of the co-sponsors of SB 11.

Other states have moved in recent years to rein in the practice. Last year, West Virginia, Iowa and Colorado enacted legislation setting rules and appeals processes for step therapy. And at least a dozen other states already have such laws in place.

This year’s legislation got bipartisan support, passing the Senate and House of Representatives, in large part because it was relatable. Plenty of families have a story about struggling with insurance companies over medications, Stefanics said.

And with rounds of changes, the measure won broad support from patient advocacy groups to pharmaceutical companies and doctors. But not everyone was on board. Insurers warn that restricting step therapy could prove costly and that those costs will eventually be passed on to consumers or taxpayers.

The Human Services Department, which manages New Mexico’s health insurance programs for low-income residents, calculated that a shift of just 1 percent of generic drugs to brand names due to ending some step therapy policies would cost about $10 million a year.

And Blue Cross Blue Shield of New Mexico calculated a version of the proposed legislation would raise drug costs for private employers and employees by about $6 million a year.

“The legislation in its original iteration would have undermined the step therapy process, offering less restrictive oversight or review of therapies so Big Pharma can continue to push high cost drugs with no accountability,” said Cathryn Donaldson, communications and public affairs director for America’s Health Insurance Plans, a trade group.

While the group is neutral on the bill that ultimately passed the Legislature, she added: “We continue to have concerns with the potential for this legislation to increase costs and drive down protections for consumers, including limitations on important tools like step therapy.”