A bill to limit health insurers from requiring “step therapy” is waiting for a vote in the House. Step therapy is a protocol establishing the order in which doctors can prescribe drugs for specific medical conditions, generally requiring patients try cheaper options before “stepping up” to more expensive treatments.
Connecticut law currently prohibits the use of step therapy for the treatment of stage four metastatic cancer, and this bill would expand that prohibition to include any behavioral health condition or a disabling, chronic, or life-threatening condition or disease.
Insurers oppose the bill, with the Connecticut Association of Health Plans testifying that the new process “would represent the single most expensive mandate ever passed.”
Organizations like the Connecticut Hospital Association, the Connecticut State Medical Society, and the Connecticut Society of Eye Physicians, support the proposal, with the Connecticut Psychiatric Society testifying that step therapy is just “a cost-saving measure for the insurance companies, and it is bad for patients.”
Sen. Martin Looney, President Pro Tempore of the State Senate, co-sponsored the bill, and testified that step therapy can delay effective treatment and hurt health outcomes for patients.
“While there are legitimate uses of step therapy, too often it is implemented in a manner that interferes with patient care and leads to insurers preventing physicians from providing the best care for patients,” wrote Looney. “Patients and providers continue to have situations in which the carriers’ step therapy policies prevent the patients from receiving the treatment that their health care providers have decided is the most appropriate.”
The proposed legislation passed the Senate 34-1, with only Sen. Rob Sampson, R-Wolcott, opposed. Similar proposals have failed in the legislature over the last few years, though previous incarnations of the bill have never made it this far.
Currently, doctors who oppose the step therapy regimen imposed by insurers must appeal the decision to insurance companies and prove why their patient needs a different medication. If this bill passes, that dynamic will be switched, so the onus will be on the insurance company to prove why the prescription is not medically necessary.
“Clinicians do not have extra hours of time on their hands to be on hold waiting for an insurance company middle management bureaucrat to argue with them over what the right therapy is,” said State Sen. Heather Somers, R-Groton.
Somers shared one example of a patient with chronic back pain who was required by their insurance company to try physical therapy and other treatments, enduring “months and months of agony” before finally being able to have the surgery their doctor wanted them to have six months earlier. She is also not persuaded by the argument from insurers that the bill will be uniquely costly.
“Insurance companies say it’s going to increase rates, but when have they ever reduced rates?” Somers said. “Everything for them increases cost. But there is also a cost associated with the patient’s quality of life.”