Senator Nancy Barto has shown great insight into the health care needs of our Arizona community in sponsoring SB1270. I have a unique perspective to being an advocate for this simple legislation. I was a Director of Pharmacy at a large health plan in this state for almost 20 years and have been involved with managed care in this state for almost 35 years. I pioneered and implemented utilization management programs in pharmacy benefits throughout my career. I believe in and support good utilization management programs. I am also a patient with complex health care needs. I have survived two different types of breast cancer, have a serious neurologic condition requiring a specialty medication, and an autoimmune disorder called Sjogrens, all which significantly impact my life.
This timely legislation is intended to establish basic guidelines for the insurance industry with regard to their industry practice called prescription medication “step therapy.” This process is currently controlled completely by the health care insurance industry, even though it directly impacts patient care.
While each health care insurance plan has its own unique and different step therapy rules, the protocol requires medical providers to prescribe certain medications before the insurance will cover certain other medications. Patients must try these alternative, and often less costly, medications and fail (as determined by the health plan) before certain restricted medications will be covered under the patient’s prescription benefit.
Currently, the Arizona insurance industry is able to create their own unique and very specific health plan policies based on internal insurance company opinions and processes. There is no oversight or accountability for the unintended consequences to these policies occurring in our community and adversely affecting lives.
On the surface, the basic concept of step therapy makes sense in light of the huge cost burden medications are putting on the health care system. However, the reality is the health care insurance industry makes these prescribing protocol rules that impact patient care with no oversight, and they have been allowed to create a process that is tremendously confusing and extremely time consuming for prescribers, patients, and pharmacies. Every year the health insurance industry requires more rules for medications covered under prescription benefits. Therefore, time is of the essence to establish basic guidelines to balance the power and disruption this industry has over the delivery of health care.
The insurance industry holds all the cards but shares no responsibility for the unintended outcomes. The industry has practices which allow them to make isolated decisions which can be different from medical best practices or keep up with the fast pace of medicine. Patients are being harmed because they and their providers are often unable to understand, endure, and participate effectively in the process.
Personally, I have had unbelievable delays with my own medications because of my health care plan which caused me to have significant medical problems. It forced me to take an honest look at a system that I helped create. I realized improvements were needed-especially as the volume of these prescription rules increases and prescribers are left with much less time to provide medical care due to the administrative burdens that are consuming not only their time, but so much of their energy.
This legislation is simple. It establishes a framework that requires health plans to use medical science fairly when creating guidelines, facilitate exceptions to step therapy when it makes sound medical sense, and it encourages at least some transparency and accountability. Based on my experience this legislation will not create costs to the insurer beyond what they should already be doing, if they are going to continue to “step” in between the prescribers and the patients as it is always a health plans choice when selecting programs to increase their profitability. I believe this legislation is a step in the right direction to create a very basic framework for health plans as they continue to decide what rules THEY chose to impose on the health care system. This is a chance to pass basic legislation in Arizona to reinforce health plans that are doing the right thing and to redirect those health plans that aren’t.
I hope to see HB1270 pass unanimously in the Arizona State Legislature, it is clearly a necessity to avoid the serious and unintended consequences happening to Arizonans who pay in advance and in good faith for their health care and prescription benefits when their medications require “step therapy.”
Kim Kelley was the head of pharmacy for a very large insurer for years.