Bills seek reform to prescription practice known as 'step therapy' | KOB 4

Bills seek reform to prescription practice known as 'step therapy'

Morgan Aguilar
January 17, 2018 06:30 PM

SANTA FE, N.M. -- Thousands of New Mexicans are paying for and taking medications that doctors have already said probably aren't going to work. Bills making their way through the 2018 legislative session are aimed toward reforming the practice known as "step therapy."


"Step therapy is when an insurance company decides what drug a patient needs based on what works for them money-wise, rather than having a doctor choose what drug a patient needs based on their health conditions," said Dr. Barbara McAneny, CEO of the New Mexico Cancer Center and president-elect of the American Medical Association.

McAneny said any New Mexican who is on a drug for a serious chronic condition is going to run into this problem. About two years ago, Ben Lewinger was diagnosed with an aggressive form of autoimmune arthritis.

"It's degenerative, meaning that the longer it goes without my symptoms being addressed. There's permanent, irreparable damage," said Lewinger, a victim of step therapy.

Lewinger's symptoms were ignored and made worse when his insurance provider refused to pay for the drug his doctor prescribed.

"Instead they insisted that we start with this other drug which is, you know, kind of an archaic drug from 60 years ago that I was forced to be on for several months that had absolutely no positive effect," he said. "It had a really bad negative effect."

Lewinger said the drug chosen by his insurance company made him sick, and he ended up paying for supplements to counteract its negative effects.

"I would take it once a week and for the 48 hours following, I was essentially useless," he said. "I used to take it on Fridays and then I realized I missed out on having a weekend with my family. I have two young kids, and so I started taking it Sunday evening and then the result was I was pretty bad at work on Monday and Tuesday.”

Lewinger was on that drug for about six months before finally getting on one that works for him. He has been taking a new one successfully for about one year now, but he's worried he will have to go through it all over again.

"I get insurance through my company and the company I work for has changed providers, and I've learned that it's not at all uncommon for new insurance companies to force patients to start over again," he said. "So right now, I'm getting ready for a fight to see if I can stay on this drug that I've been on for the last year that's working instead of starting over."

McAneny said step therapy could have deadly consequences, and she says it doesn’t actually save insurance companies any money.

"Health plans often claim that this will save money. But back in 2008, Georgia Medicaid did a study on step therapy and they found that they save $19 per patient per year on the drug," she said. "But they spent $31 per patient for a year on hospitals and emergency departments because of the problems from getting the less appropriate drug."

Even if the process did save the companies and patients money, both McAneny and Lewinger say it’s not worth it.

"Whatever cost savings there is on the insurer provide, doesn't make up for me suffering for an additional six months, doing more permanent damage to the joints in my hands and fingers," said Lewinger.

"We believe that doctors should determine what drugs patients get so that they get the right drug for the right patient at the right time, not insurance companies to maximize revenue,” added Dr. McAneny.

Senate Bill 11 and House Bill 42 would require step therapy to be based on evidence instead of money, and they would increase transparency throughout the process.

"A lot of pharmacy benefit managers, which are companies hired by health plans, will select drugs based on how much money it makes for them, not whether it's best for the patient,” McAneny said.

Lewinger hopes these bills are signed into law to prevent anyone else from suffering the way he has.

"It's really awful," he said. "It completely undermines the relationship between a doctor and his or her patient."


Morgan Aguilar

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