What We Need
Although any progress on step therapy reform is typically better than the status quo, the ad hoc approach some states take creates barriers to additional reforms. Chief among these barriers is the fact that legislators are often reluctant to revisit matters they thought were fully resolved. For this reason, the ACR supports step therapy reform that includes the following:
- Clear step therapy protocol guidelines that allow for overrides when:
- A medication is contraindicated;
- A patient has already failed the medication;
- A patient is stable on their current medication;
- A 24-hour decision window for emergency override requests;
- A 72-hour decision window for non-emergency override requests; and
- A clear and expedient appeals process.
What We Have
Many states enact laws that include only some of these provisions. Practitioners in states that do not have a comprehensive step therapy law often report that there has been no improvement in step therapy override processes or the paperwork associated with getting an override approved. California is perhaps the best example of this phenomenon.
The ACR has had substantial feedback from California physicians indicating the paperwork required for step therapy override requests has not been reduced. The enforcement mechanism to punish violators of the statute is also inadequate. California is not alone in problematic approaches to step therapy.
Ohio passed step therapy reform late last year. This bill was widely championed as a substantial late session win. Although the bill contains much to praise, one section of problematic language in the step therapy override exceptions has started to show up in step therapy bills in other states: Patients who are stable on their current medications can remain on them, but this exception allows insurers to require patients try a pharmaceutical alternative from the FDA’s orange or purple book before the insurer is required to cover the patient’s medication. This bill will not go into effect until January 2020, so the jury is still out on how this loophole will affect patients, but the impacts could be significant and disruptive.
This type of loophole has led many to begin to call for a federal solution. Although the federal government can provide relief in such programs as Medicaid and Medicare, it has historically deemed the regulation of private payers to be the province of the states. That is why is we continue to work with partners to identify problems in existing step therapy statutes and promote comprehensive step therapy laws in states that are considering reform.
Fortunately, the two new laws enacted this session take a more comprehensive approach. The Virginia and Georgia laws both have all of the essential elements outlined above. The ACR was involved in coalition efforts to secure these bills and thanks all Virginia and Georgia rheumatology leaders who worked locally to achieve these successes in their states. In Georgia and Virginia, we had more than 20 meetings with legislators, attended multiple advocacy days and wrote or signed onto letters urging governors to sign bills. We also signed onto broad coalition letters and worked with patient groups, and members were able to urge their legislators to support the legislation, resulting in at least 29 physicians engaging directly with their legislators.
As successful as these efforts were, it is important we monitor the regulations created to enact them as these laws move forward in the implementation process. Too often, laws created with the best of intent go unenforced, because departments lack funding and bandwidth to fully enforce them.
Get & Stay Informed
It is important for rheumatology professionals and the chronically ill to stay abreast of the latest changes in step therapy laws. Being active in rheumatology advocacy through the ACR and your state/local society communications are great ways to stay current. Also, the National Psoriasis Foundation has a useful tool that offers a brief overview of state laws and how to navigate the override process. View and use this tool by clicking here.
Encourage your patients to become more educated on these matters. Aside from producing a patient population that is more educated and engaged in their own care, it will produce a patient population that is more educated and engaged in policy.
Advocacy can be a difficult undertaking, but when patients and providers come together we can produce significant change that puts the provider-patient relationship first. To get involved in advocacy in your state, contact your state/local rheumatology society or Joseph Cantrell, senior manager of state affairs for the ACR, at firstname.lastname@example.org.