Legislation to ban so-called “step therapy” – backed by a number of health experts but opposed by some health-care insurers – is being debated in the Capitol as lawmakers eye a relatively unknown aspect of modern health care.
Step therapy is a process followed by a number of health insurance companies. A bill to ban the practice, AB 1826 by Jared Huffman, D-San Rafael, was approved 45-26 by the Assembly and is heading to the Senate.
Step therapy, critics say, involves preventing patients from using the use of the most up-to-date pain medications prescribed by their physicians until after they have used older, less expensive, first-line and often over-the-counter or generic medicines. They contend that patients have been forced to use up to five different medications before they can receive access to the medicines they originally requested – a process that they say drives up costs.
But supporters of step therapy sharply disagree. Blue Shield of California said that “step-therapy protocols also act as a check-and-balance to the cozy relationship that exists between many physicians and drug companies.”
The California Association of Health Plans has also opposed the bill. “We are opposed to AB 1826, which will override the standard medical practice of using step therapies – having patients take the safest, most cost-effective drug therapy first, progressing to more risky or costly therapies only if necessary. In essence, step therapy has a patient try a safer, non-addictive drug before moving to more serious drugs like OxyContin,” stated CAHP President & CEO Patrick Johnston. “Last month, the National Drug Control Policy Director called prescription drug abuse ‘the fastest-growing drug problem in the United States.’ The government estimates a 400 percent increase in people receiving treatment for addiction to prescription pain killers from 1997 to 2007. When we have a serious problem of addiction to prescription medication, is it wise to make these drugs more easily available?”
Johnston explains that step therapy often allows patients to be treated with safer, more established drugs before being placed on drug therapies that could have harmful side effects. “Sometimes patients are harmed by an error in the prescription or in the use of a medication. In its noted report, To Err is Human, the Institute of Medicine reports that about 90,000 to 400,000 people are harmed or killed because they received the wrong drug or used the right drug in the wrong way. The California Health Care Foundation also reported recently that many physicians do not have an adequate process in place to receive the latest information about drug dosage or interaction issues.”
Step therapy also provides financial benefits. Prescription drugs are one of the major drivers of health care costs, consuming a significant 16 percent of the health premium dollar. “By 2017 spending on prescription drugs is projected to increase 70 percent over what was spent in 2008, climbing from $802 to $1,367 per person,” Johnson explained. “Prescription drugs are one of the major drivers of health care costs, consuming a significant 16 percent of the health premium dollar.” He went on to point out that the state is exempting itself from the ban on step therapy, forcing private employers, and not CalPERs, to shoulder the cost.
A study by the American Journal of Managed Care to determine whether step therapy increased or decreased costs proved inconclusive.
After examining patients who used anti-hypertensives (drugs used to treat high blood pressure) from 2003 to 2006, the study discovered a 3.1 percent reduction in medication costs after step therapy was used. But the study also noted that patients in step-therapy plans had higher visits to emergency rooms and hospitals, with $99 in higher-than-average expenditures. The study concluded more research needed to be done on the topic.
Supporters of Huffman’s bill include The American Pain Foundation, Alliance for Patient Access, American GI Forum of California, Association of California Neurologists, Healthy African American Families, National Multiple Sclerosis Society, California Chapters; the Urban Health Institute and several more organizations have all expressed support for AB 1826. It was heard in the Senate Committee on Health on June 30.
According to an Assembly analysis, chronic pain affects more 76 million people and those that suffer from it are frequent visitors to California’s emergency rooms and hospitals.
Chronic-pain victims, as well as patients suffering from fibromyalgia, neuropathy, multiple sclerosis, arthritis, cancer, and diabetes-related pain, among numerous other conditions are effected by step therapy. New Jersey has already banned step therapy, the only state to do so.