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Commenting for this proposal will be open until the close of business on Monday, June 5.
Title of Proposal:
Support HB1755 and SB1408
On behalf of:
Medical Society of Northern Virginia
Describe the Idea or Issue:
Step therapy occurs when a doctor prescribes a treatment, but the insurance company requires the patient to try one or several other drugs first, with no medical justification. The patient must wait for the doctor prescribed treatment, often for weeks, months or even years, as he or she tries each of the insurer-mandated drugs one-by-one, and proves that the insurer’s preferred treatment didn’t work.
Virginia can take Step Therapy in the Right Direction
House Bill 1755 would make step therapy better and safer for Virginians – without inhibiting insurers’ ability to safely use step therapy to save money.
- Better Step Therapy: House Bill 1755 and Senate Bill 1408 put an online process in place for health care providers to request overrides for step therapy protocols and ensures that providers are notified in writing if their request is denied.
- Safer Step Therapy: House Bill 1755 and Senate Bill 1408 help ensure that overrides are granted for Virginians for whom the insurer-mandated drug is clinically determined to cause adverse health events or be ineffective, as well as those who have already met step therapy requirements to receive the same treatment.
- In this capacity, House Bill 1755 and Senate Bill 1408 make step therapy more effective at saving money for insurers and the state alike, as these Virginians are more likely to miss work and require additional in-patient care, hospitalization, and ER visits if they go without the treatment plan prescribed by their health care provider.
Step therapy is harmful for Virginians
Insurers use step therapy to cut down on medication costs, and sometimes the insurer-mandated drugs can even end up working for the patient.
But far too often, step therapy keeps Virginians living with dangerous and even life-threatening conditions – from mental illness and cancer to epilepsy and autoimmune diseases – from the therapies they need, causing adverse reactions and allowing their health to deteriorate.
- Step therapy second-guesses a doctor’s orders by assuming that the insurance company – not the doctor – knows best. Step therapy protocols have no medical justification.
- For Virginians who rely on prescription therapies to stay healthy, productive and out of the hospital, step therapy increases health care and societal costs. In a study comparing spending on schizophrenia medications, step therapy saved $19.62 per-member per -month in atypical antipsychotic expenditures. However, these savings were “accompanied by a $31.59 per-member per-month increase in expenditures for outpatient services.” As a result, step therapy increased health care costs. Similar findings have been observed when step therapy was applied to blood pressure medications.
- Step therapy can prevent Virginians from receiving treatment at all. In fact, studies have shown this to be true for one in five patients.-7
- Farley, J. et al., “Retrospective assessment of Medicaid step-therapy prior authorization policy for atypical antipsychotic medications,” Clinical Therapeutics, 30: 1524-1539, 2008.
- Mark, T. et al., “The Effects of Antihypertensive Step-Therapy Protocols on Pharmaceutical and Medical Utilization and Expenditures,” American Journal of Managed Care, 15: 123-131, 2009.
- Cox ER et al. “Health plan member experience with point-of-service prescription step-therapy,” J Manag Care Pharm. 2004;10(4):291-98.
- Clinical and financial outcomes associated with proton pump inhibitors prior-authorization program in a Medicaid population,” Am J Manag Care. 2005;11(1):29-36.
- Motheral B.R. “Pharmaceutical Step-Therapy Interventions: A Critical Review of the Literature,” J Manag Care Pharm. 2011;17(2):143-55.
- Yokohama K et al. “Effects of step-therapy program for angiotensin receptor blockers on antihypertensive medication utilization patterns and cost of drug therapy,” J Manag Care Pharm. 2007;13(3)235-44.