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Kruse Wants Easier Over-Ride of Denial by Insurers of High-Cost Drugs

Senate Bill 526 outlines a process that patients and physicians could use to get health insurers to cover medications. Insurers often balk at the price of these drugs and try to force the patient to first try a cheaper alternative.
February 22, 2017

Patient advocates and pharmaceutical companies are backing legislation that would give physicians an easier time prescribing medication and bypassing “step-therapy” protocols, which health insurers use to limit the dispensation and purchase of high-cost drugs.

Senate Bill 526 modifies the state law governing the use of step-therapy and would require health insurers to respond more immediately to physicians when they deny a claim for a medication and give the physician a more straight-forward and prescriptive means of demanding that a patient be given access to a specific medication.

“It’s all a matter of getting patients the care they need,” said Sen. Jeff Kruse, R-Roseburg, the chief sponsor of Senate Bill 526, along with Sen. Lew Frederick, D-Portland.

Health insurers often require consumers to try a medication on an insurer’s formulary for a given diagnosis, and only after that fails may they try a preferred, brand-name medication, which often costs the health insurer significantly more money, which in turn drives up the cost of insurance premiums.

“As an individual, I don’t believe there should be so many detours to getting the care that I need,” said Chris Pettit, who takes medication for psoriasis.

Dr. Shawn Macalaster, a Hillsboro rheumatologist, said the paperwork and bureaucracy that currently needed to be navigated were so arduous that his practice had to hire a full-time administrative assistant just to work on appeals. “Step-therapy has caused a barrier to the practice of medicine,” he said.

Patrick Stone of the National Psoriasis Foundation said in the worst circumstances, patients may have to restart the step-therapy process simply because their employer assigns them to a new healthcare plan or they begin a new plan year. SB 526 would allow patients to stay on the drugs that they have already been getting.

Health insurers and some coordinated care organizations, including the two in central Oregon managed by PacificSource, oppose the bill.

“Our goal is to make sure that our members get access to treatments that will cure their diseases,” said Tom Holt, the lobbyist for Regence BlueCross BlueShield. “It’s all based on medical evidence and peer-reviewed literature.”

Holt said step-therapy was an unfortunate process that health insurers implement because of the extremely high prices that drugmakers have set in the United States compared to other developed countries. He said the auto-immune drugs like those that Macalester prescribes costs $1000s every month. “Some of those are among the most expensive drugs on the market.”

Regence, he said, employs an expert team on its pharmaceutical and therapeutics committee to decide medication formularies.

Both Kruse and Holt evoked the late Sen. Alan Bates, D-Medford, who died in August after 25 years of shaping Oregon health policy, often from the caring viewpoint of an osteopathic family care physician.

Kruse said Bates had planned to introduce SB 526 while Holt said that Bates had worked with him two years ago to hash out the current statute.

Curtailing the use of step-therapy protocols has been on the agenda of patient advocacy groups and the Pharmaceutical Research and Manufacturers Association across the country. They have succeeded in passing legislation similar to SB 526 in a handful of other states, including New York and Illinois.

Over in the House, Rep. Rob Nosse, D-Portland, has introduced legislation to corral the cost of high-priced pharmaceuticals by requiring manufacturers to rebate health insurers for costs that are excessively higher than what other first-world countries have negotiated.

Nosse’s bill, HB 2387, may eliminate the need for health insurers to implement complicated step-therapies that keep patients from getting the drugs they prefer, since the health insurer would not face the full brunt of these high-cost medications.

It’s unclear whether the health insurance lobby would drop their opposition to SB 526 if they got this protection in HB 2387, which Holt has wholeheartedly endorsed.

Chris can be reached at [email protected].