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By Andy Metzger

STATE HOUSE, BOSTON, DEC. 14, 2017.....The insurance companies that pay for medical treatment often stand in the way of the most effective drugs, physicians and patients told lawmakers Thursday, asking them to require exceptions to the usual protocols.

Dr. Eric Wong, a neurologist and oncologist, said that he watched "helplessly" as his patient Deborah Fox made several trips to the emergency room while awaiting her insurer's approval for migraine medicine.

"Sometimes I go blind from the pain," Fox told members of the Financial Services Committee Thursday. She said, "I've never experienced anything like this in my entire life, and I gave birth to three sons naturally. This was worse."

Doctors and patients suffering from arthritis, Crohn's disease and other ailments asked lawmakers to support legislation (H 492/ S 551) sponsored by Rep. Jennifer Benson and Sen. Barbara L'Italien.

The bills address an insurance industry protocol called step therapy. Insurers use step therapy to manage costs in the search for effective treatment, directing patients first towards more affordable generic drugs before authorizing reimbursement for more expensive brand-name medications. This approach can lead to disagreements as insurers are sometimes reluctant to cover a doctor's prescribed treatment, forcing patients to either go without it or pay out of pocket as they and their doctors try to convince the insurance plan to cover the medication.

The legislation would establish procedures for prescribers to request an exception to insurers' usual protocols if certain conditions are met, and require criteria – such as peer-reviewed publications – to establish insurers' step therapy protocols, according to a bill summary. The National Multiple Sclerosis Society said the bill would also improve the process for appealing coverage denials "with increased transparency for patients and providers."

While Michelle Dickson, of the National Multiple Sclerosis Society, said the bill provides a "reasonable balance," a major insurer claimed it would require studies that are non-existent.

"These bills would prohibit step therapy unless it is based on an independent study that specifically outlines the precise order in which drugs should be taken," Blue Cross and Blue Shield of Massachusetts Vice President of State Government and Regulatory Affairs Michael Caljouw wrote to the committee's chairmen – Rep. Aaron Michlewitz and Sen. Jamie Eldridge. "Unfortunately, such studies simply do not exist for the vast majority of treatments."

No one spoke in opposition to the bill during Thursday's hearing, and the patients and doctors who described hardships made an impression on Michlewitz and Eldridge.

"Step therapy is not working for many patients," Michlewitz told the News Service after the hearing. The committee is "taking a hard look" at whether to advance the bill this session, he said.

The committee advanced the bill last session before it died in the House Committee on Ways and Means. House lawmakers are assembling a health care package, and Michlewitz said he did not know whether step therapy would be addressed in that bill.

A proponent of a Medicare-for-all approach to health insurance who believes government control would remove barriers between patients and prescribed drugs, Eldridge said insurers create hurdles to effective treatment to protect their own profits.

"It's about cost. It's about protecting health insurance companies' profits. I think that's very troubling," Eldridge said. "I'm certainly going to take a very strong look at the bill."

Cost is a major concern not just for insurers, but for consumers, state policymakers and business leaders as well. Cost-control was the stated purpose behind a Senate bill to overhaul the health care landscape earlier this year.

In 2015 spending on pharmaceutical drugs increased by $8.1 billion, or more than 10 percent over the prior year, according to the Center for Health Information and Analysis.

"Step therapy is a tool used by Medicare, Medicaid and commercial health plans across the country to ensure that members have access to clinically appropriate and cost-effective medications," Caljouw wrote. "When there are more than one established clinically-effective treatments for the same diagnosis, public and private payers generally cover the less expensive option unless there are clinical indications that it will not be effective for a particular patient."

Doctors said they have become frustrated by the processes insurers require them to follow if their medical recommendations don't match up with insurers' step therapy.

In a typical situation, a patient will learn at the pharmacy that the insurer has denied coverage for a medication, requiring the doctor to go through a "prior authorization" procedure and possibly confer with a peer at the insurance company to seek approval, said Dr. Steven Fine, who is chief of gastroenterology at Metrowest Medical Center.

"It could take weeks," Fine said.

Eric Linzer, of the Massachusetts Association of Health Plans, said step therapy is not typically used for life-threatening conditions, and he said there are already processes for appealing insurance coverage, including going to the Office of Patient Protection at the Health Policy Commission. That office only received 39 appeals that dealt with prescription drugs in 2015, Linzer said.

Patients and their families are frustrated, too.

"I spend more time on the phone yelling at my insurance company than I do caring for my husband," said Donna-Lee DePrille, of Westfield, who is the caregiver to her husband, a former truck driver who has myasthenia gravis, a muscle-weakening disease.


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