It's a fairly simple concept: When ill, you seek effective treatment from your doctor. Despite efforts by some Maryland health insurers to insert themselves into the middle of the physician-patient relationship, lawmakers are poised to make this simple idea — that doctors are the correct people to decide treatment for their patients — a reality for Maryland patients. Important patient protection legislation is working its way through the Maryland General Assembly after clearing key hurdles in both chambers and should soon end up on the governor's desk.
A bill introduced by Sen. Thomas M. "Mac" Middleton and Del. Eric Bromwell is common-sense legislation that would bring about real change for Maryland doctors and patients by lessening the impact of a harmful health insurance cost containment practice known as "step therapy." Step therapy, sometimes called "fail-first," effectively means that a health insurance company or pharmacy benefit manager (PBM) can decide if they think a doctor's prescription is the "right" one for a patient. If the insurer or PBM thinks a patient can be treated with a less costly therapy, it will not cover or pay for what the doctor ordered and will instead insist the patient try the less costly therapy first. If the patient fails to gain back health after that first "step," an insurer or PBM can mandate a second step or even a third step before agreeing to cover what the doctor initially prescribed for their patient.
Not only is the practice of step therapy inefficient, it also takes responsibility for the health care of that patient out of the hands of trained physicians. Health insurance companies and PBM bureaucrats should not be practicing medicine.
Health insurance companies put step therapy and similar practices in place with intention of saving money. Doctors agree that saving money in our over-burdened health care system is a worthy and righteous cause. Generally speaking, doctors will always prescribe a generic drug or seek out the less expensive treatment, but only if it will be effective enough to send their patient back to work or school and to achieve good health without unnecessary delay.
Contrary to the goal of cost-containment, evidence suggests that step therapy may actually increase overall health care costs. Patients forced to manage multiple insurer "steps" often endure additional trips to the doctor or pharmacy, with additional time off from work or child care. When patient treatment is unnecessarily delayed, patient health deteriorates and manageable conditions devolve into more difficult to manage diseases. When patient sickness is prolonged by step therapy, employers lose productivity, and the health care system incurs additional costs in the form of increased emergency room visits and hospitalization.
The Maryland Health Care Commission recently studied step therapy and made recommendations on how to rein in the most egregious aspects of the practice, and Senator Middleton and Delegate Bromwell introduced legislation (SB 622/HB1233) to codify some of the recommendations. The Middleton/Bromwell legislation does not eliminate step therapy. It prevents insurers from forcing patients who are already being effectively treated on a medication to undergo the step therapy process and also prohibits insurers from forcing patients to try medicine the FDA has not approved for treatment of a specific condition. Maryland would be the first state in the country to enact the latter provision.
The legislation has broad support from both doctors and patient groups. This is an opportunity for Maryland lawmakers to help ensure that the health care of their constituents is provided by a doctor and not an insurance company or PBM and that patients receive the most effective treatments based on health considerations and not a health insurance company's bottom line.
We hope that the interests of patients carry the day.
Gene Ransom III is the CEO of MedChi, the Maryland State Medical Society, the largest physician organization in Maryland. He can be reached via Twitter, @GeneRansom, and email at email@example.com.
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