Opinion

Eliminate the guessing game in step therapy

A doctor writes out a drug prescription for a patient. (Photo: Lisa-S, via Shutterstock)

Delays in care and treatment are utilization management tools developed by the insurance industry and are respectively known as step therapy and prior authorization.  Insurers are using them at increasing rates throughout the country and in California.

Step therapy forces patients to try insurer-preferred medications before approving the medication initially prescribed by the doctor. Utilized by both public and private insurers, step therapy undermines the clinical judgment of doctors and puts patients’ health at risk.

The bill, AB 347, will ensure that doctors and their staff are not playing a guessing game as to what exceptions will be granted by the insurer.

2021 is the time for the California Legislature to address concerns from the patient and provider community about step therapy. We are asking to strike the right balance between allowing insurers to use utilization management protocols while putting in place guardrails that protect the patient and lessen the burden on health care providers.

In response to the needs of patients and physicians, Assemblymember Dr. Joaquin Arambula recently introduced AB 347.

AB 347 will enact a standardization of exceptions when an insurer utilizes step therapy.  The bill does not seek to eliminate step therapy but will ensure that doctors and their staff are not playing a guessing game as to what exceptions will be granted by the insurer and when patients might have access to the medication their doctor prescribed.

These standard exceptions offer real patient protections, including ensuring that patients will not have to try a medication they’ve already failed, even if they change insurance companies.  Additionally, patients will not be forced to try a medication that could cause an adverse reaction based upon clinical guidelines.  The bill will also establish standard timelines for responses from insurers when step therapy is applied.

Through these measures, the bill aims to prevent unnecessary harm to patients while avoiding added costs to the health care system. Continuing to delay care and  force patients to take medications that they will never stay on will only lead to further costs in the form of unnecessary use of medications, unnecessary emergency room visits, and unnecessary surgeries and care.

AB 347 will also bring added transparency around utilization management protocols. This includes insurers providing the Department of Managed Health Care and other regulatory bodies with data on how often these protocols are being used, as well as how often they are approved or denied.

It will also require that the utilization management reviewers employed by the insurers are qualified in the specialty that they are reviewing. For example, a rheumatologist should be the one reviewing requests submitted by a rheumatologist.

No patient should be forced to endure ineffective treatments just to satisfy an insurer’s unnecessary utilization management process. Rather, the patient’s relationship with his or her doctor – and that doctor’s understanding of the patient’s disease and unique medical history – must remain paramount in the clinical decision-making process.   Similar legislation has been passed into law in over two dozen other states across the country.

It’s California legislature’s turn to stand up for the millions of Californians living with rheumatic diseases and other chronic conditions by supporting this common-sense legislation and passing AB 347 quickly this session.

Editor’s Note: Samy Metyas, MD, is president of the California Rheumatology Alliance. Wesley Mizutani, MD, is the chair of the California Advocacy Committee for the Arthritis Foundation.


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