October 13, 2021


BOSTON, MASSACHUSETTS, UNITED STATES, October 13, 2021 /EINPresswire.com/ -- Today, patients and healthcare providers from across the Commonwealth met virtually with members of the legislature and their staff to urge support of common-sense patient protection legislation aimed at getting patients the right medication at the right time.

When passed into law, H. 1311 / S.756 will put parameters around the insurance industry practice known as ‘step therapy’ or ‘fail first’ by ensuring patients and their providers can access a medically reasonable and expedient step therapy appeals process. Step therapy occurs when a patient’s insurer refuses to cover the cost of a prescribed medication until the patient tries and fails on a different medication dictated by the insurer.

Step therapy protocols can be harmful to patients both financially, emotionally, and physically, causing an undue wait for the proper treatment and in some cases a worsening of a person’s medical condition. Step therapy does not consider an individual’s medical history or other factors, but instead relies upon a pre-determined prescription drug formulary.

Brittany Ricci, a patient who went through step therapy and is currently doing a medical residency talked about the health consequences she experienced.

“I was just about to begin studying medicine at Brown when my Crohn’s disease escalated. My doctor prescribed me one treatment, but my insurance company forced me to take another. During the “fail first” period, I had 3 surgeries, severe infections, and landed in the ER numerous times because of fever, dehydration, and other serious symptoms, "Ricci said. "Thankfully when I finally got on the right treatment, my condition improved and now, I’m doing my residency in Boston. As a doctor, I want to do everything in my power to help my patients get the medicine I prescribe, when I prescribe it.”

Jenna Green, a multiple sclerosis patient, emphasized she had met with her world-renowned neurologist for three hours and together they came up with a treatment plan that he felt was right for her.

"On the day of the first infusion my neurologist had prescribed and was told that my insurer was denying it. I couldn't believe it," said Jenna Green. "I had been newly diagnosed with a life-changing, degenerative disease, my world was upside down, and now someone who has no idea as to why my doctor prescribed this specific medication, was saying 'no'. They wanted me to try and fail on their preferred drug first. No two patients are the same and there was a reason my doctor prescribed the medication that he did. Navigating the appeals process was very stressful. Maintaining a quality of life for patients like me is dependent on the passage of these bills."

Marissa Shackleton, Executive Director of The Elliot Lewis Center for Multiple Sclerosis Care in Wellesley, told lawmakers the center has two full time employees whose jobs are nearly exclusively to manage insurance authorizations and appeal step therapy requirements. They recently received a denial due to step therapy criteria for a patient who has been on the same therapy for 15 years but recently had a change in insurance.

"In order to appeal a step therapy requirement, our office completes an authorization request through the insurance and/or specialty pharmacy. If the patient doesn’t meet the step therapy criteria, our office then needs to submit an appeal defending the physician’s decision for the medication," Shackleton said. "This may be required to be submitted online, by phone or by fax. It can take up to 30 days to receive a decision, and if it’s not approved, we may need to submit a second level appeal or request a physician review. This can leave a patient with a debilitating disease without medication for several weeks, or even months."

Dr. Eric Wong, a board member and past president of the Massachusetts Society of Clinical Oncologists, talked about an experience he had with a patient, who ended up in the emergency room multiple times because of step therapy.

"I do not think that patients should have to beg for their medications when they use their hard-earned money to pay for their insurance premiums," said Wong. "There needs to be a mechanism to release an emergency supply to the patient in more urgent situations. Doing so would take care of what the patient needs medically and prevent even costlier trips to the emergency room."

"No one should have to jump through hoops to get the medicine their doctor prescribes in a timely manner," said Representative Marjorie Decker, D-25th Middlesex, and a co-sponsor of the House bill. "This legislation doesn't prevent health insurers from using step therapy. It just provides transparency, a timely appeals process, and a clear pathway forward for doctors and patients to bypass it when medically necessary. I was first made aware of the painful obstacle that exists for many patients by way of a constituent who was forced to needlessly suffer and lose precious time, only to go through a medical bureaucracy, not informed by her doctors. Insurance adjustors should not stand between a patient and life-saving care prescribed by their providers."

"This legislation puts in place important protections for thousands of patients living with chronic diseases. The voices we heard from today were powerful," said Representative Jeffrey Roy, D-10th Norfolk, and a co-sponsor of the House bill. "It's my hope that my colleagues will understand just how necessary it is for us to act fast. If there's one thing the COVID-19 pandemic has taught us, it's that getting patients timely access to the medication their doctor says they need, is of utmost importance."

"Patients with complicated illnesses should be receiving the medications that their doctors know they need — not repeatedly taking medications that they know to be ineffective just to help insurers save on costs," said State Senator Julian Cyr, D-Truro, and Chair of the Joint Committee on Mental Health, Substance Abuse, and Recovery. "Step therapy is a shortsighted practice that puts patients at unnecessary risk; it takes lower costs today in exchange for more harm, more hospitalizations, and more spending in the very near future."

Marc Hymovitz, the Director of Government Relations for the American Cancer Society Cancer Action Network, and the Chair of the MA Fail First Coalition, said patient advocacy groups are anxious to get the legislation over the finish line.

"On behalf of the more than 50 patient and provider groups that support this bill, I would like to thank Representatives Decker and Roy and Senator Cyr for hosting this briefing and for sponsoring this important legislation," said Hymovitz. "Step therapy impacts thousands of people in Massachusetts, and ensuring they have access to specific medication, when they need it, is critical. The language included in these bills is a win for everyone."

Nearly three dozen other states have passed similar laws.

Groups Supporting H.1311 and S.756 include:

AIDS Action Committee of Massachusetts
Aimed Alliance
Allergy & Asthma Network
Alliance for Patient Access
Alpha-1 Foundation
American Academy of Dermatology
American Autoimmune Related Diseases Association
American Cancer Society Cancer Action Network
American College of Gastroenterology
American College of Rheumatology
American Diabetes Association
American Gastroenterology Association
American Heart Association (supportive but pending approval to add to leave behind)
Arthritis Foundation
Asthma and Allergy Foundation of America, New England Chapter
Cancer Support Community
Chronic Disease Coalition
Coalition of State Rheumatology Organizations (CSRO)
Color of Crohn’s and Chronic Illness (COCCI)
Community Oncology Alliance
COPD Foundation
Crohn’s & Colitis Foundation
Epilepsy Foundation
Family Reach
Global Healthy Living Foundation
Greater Boston Sickle Cell Disease Association
Hemophilia Federation of America (HFA)
Hypersomnia Foundation
International Cancer Advocacy Network (ICAN)
Leukemia & Lymphoma Society (supportive but pending approval to add to leave behind)
Lupus and Allied Diseases Association, Inc.
Lupus Foundation
Lupus Foundation of New England
Massachusetts Association for Mental Health
Massachusetts Biotechnology Council
Massachusetts Gastroenterology Association
Massachusetts Medical Society
Massachusetts Pain Initiative
Massachusetts Rare Action Network
Massachusetts Society of Clinical Oncologists
Multiple Sclerosis Association of America
National Alliance on Mental Illness, Massachusetts
National Eczema Association
National Infusion Center Association
National MS Society
National Organization for Rare Diseases (NORD)
National Patient Advocate Foundation
National Psoriasis Foundation
New England Hemophilia Association
Patients Rising
Rare New England
Susan G. Komen New England
US COPD Coalition
ZERO: End of Prostate Cancer

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