Massachusetts lags more than two dozen other states in placing stronger guardrails around the health insurer practice of requiring patients to use lower-cost drug and treatment options at first, exacerbating health risks and creating unnecessary stress for many families, supporters of reform legislation told lawmakers on Tuesday.
A coalition of more than 50 patient and medical provider advocacy groups on Tuesday pressed the Joint Committee on Health Care Financing to advance re-filed legislation (H 1311 / S 756) that would amend the use of "step therapy," in which a health plan declines to cover a prescribed option until after a patient tries a cheaper alternative.
"We've heard countless stories of patients being forced to take drugs that their health insurers want as opposed to what their doctors think is best," said Rep. Jeff Roy, a Franklin Democrat who filed the House version of the bill. "Sometimes, patients are made to go through step therapy multiple times, and, defying logic, some are made to try and fail on drugs they've already failed on previously, causing them intense stress and disease progress."
One of those patients is Jenna Green, who told lawmakers that her doctor recommended a disease-modifying therapy to treat her multiple sclerosis only for her health insurer to deny coverage.
"I knew that having a drug fail me would cause often irreversible mental and physical damage to my body and my mind, with hospitalizations, rehab and permanent increased disability prior to the possibility of being granted access to the medication my doctor had prescribed," Green said.
The bill that Roy and Sen. Julian Cyr filed, which they described as compromise legislation, would require health plans to offer an expedited appeal process through which patients could challenge the requirement to begin treatment with a cheaper option than their physician suggested.
Medical professionals would also gain new authority to circumvent the step therapy process in cases where doing so is necessary for a patient's well-being, and patients could be exempt from trying the same insurer-mandated medication that had previously failed to work for them.
Marc Hymovitz, who is leading the coalition of groups supporting the legislation, told the News Service that patient groups, lawmakers and insurers worked together to get the legislation "to a point where everybody's concerns are addressed."
"If insurers in the other 30 states can handle implementing the bill, then there should be no reason why we can't do it here in Massachusetts as well," he said.
Lora Pellegrini, president of the Massachusetts Association of Health Plans, said Tuesday that tools such as step therapy "provide value by ensuring patient safety and controlling health care costs."
"Step therapy encourages prescribers to use prescription drugs that are safe, clinically appropriate, and cost effective before using drugs that could pose safety concerns or clinical concerns or have higher costs and (are) used in limited circumstances," Pellegrini said in a statement.
Pellegrini said MAHP worked with advocates on the Roy-Cyr bill to find compromise. She said "while some issues remain," she is "confident" that insurers, patient groups and lawmakers can resolve them "in the coming weeks" to advance a bill.
"MAHP supports legislation that includes a transitional period to promote continuity of care and avoid interruptions in drug therapy when a member is using a drug successfully and changes plans," she said. "We look forward to working with the Legislature to ensure the bills include a clear definition of step therapy protocols so that patients can continue to access their medication without interruption or delay in treatment."
At least 30 other states have implemented reforms to step therapy, which opponents sometimes refer to as "fail first" medicine, but similar efforts in Massachusetts have fallen short.
Supporters have filed legislation seeking changes to step therapy for several sessions in a row. The Senate unanimously passed a virtually identical version of the latest bill in July 2020, but the House never advanced it to a vote before the two-year session ended.
"We feel that conversations we've had with legislators have made progress," Hymovitz said, noting that the COVID-19 pandemic absorbed much of Beacon Hill's attention last year. "They've been hearing the negative impacts on patients similar to what was heard at the hearing, so we are definitely optimistic that we'll get it across the finish line this session."
Sen. Cindy Friedman, who co-chairs the Health Care Financing Committee, said in a Tuesday interview that she believes the Legislature should address step therapy "right away" and indicated she would ask her fellow co-chair, Rep. John Lawn, to consider advancing the bill "sooner rather than later."
"We know what we need to know. It's not complicated what is going on there," Friedman said. "The bill that's there pretty much represents a compromise. It's absolutely abhorrent that people have to go through what they have to go through to get a drug, especially when they've gone through one time already."