September 29, 2016

The Virginia General Assembly’s Health Insurance Reform Commission (HIRC) met on Sept. 27 to discuss “fail first” step therapy protocols used by health insurers to manage medication and other services. This process requires patients to try one or more medications specified by the insurance company, typically a generic or lower cost medicine, to treat a health condition before “stepping up” to another medicine that may be more expensive.

Background
During the 2016 General Assembly session, Del. Glen Davis (R-Virginia Beach) and Sen. Bill DeSteph (R-Virginia Beach) introduced legislation that would have established override processes for physicians to get patients to a recommended drug or therapy faster. Both bills were “carried over” for review in advance of the 2017 General Assembly.

The Virginia General Assembly felt there was more work to do on this issue before it could move forward. During the meeting, Medical Society of Virginia (MSV) and Psychiatric Society of Virginia (PSV) member Kent McDaniel, M.D. testified about how step therapy negatively impacts the physician-patient relationship and patients’ access to efficient care. As a medical director of a public mental health service agency, he shared his own experiences of wasted hours attempting to navigate insurance authorizations and their complicated algorithms, which can cut down on patient time. He argued that the algorithms are designed for a broad stroke of patients with a disease or disorder and that different patients react differently to medications. 

In response to his testimony, the Virginia Association of Health Plans (VAHP) defended “fail first” protocols to control overutilization and unnecessary care and cost. It argued that insurance company committees can best determine which therapy will work for majority of patients.

HIRC Chair Del. Kathy Byron (R-Bedford/Lynchburg) and Sen. Rosalyn Dance RN (D-Petersburg) challenged the notion that a committee would more effectively determine treatment than the health professionals treating the patient in the field. Sen. Dance and Del. Byron expressed concerned about these committees and the specialists or lack thereof that participate and determine “fail first”.

MSV and PSV thank Dr. McDaniel for representing the physician profession and sharing his personal examples of how step therapy can interfere with the practice of medicine. We will continue to watch this issue closely during the 2017 General Assembly session to ensure that health care in Virginia is not compromised.
 

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