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Times-Union: Patients, medical groups call on Albany to limit ‘fail first’ insurance policies

By Claire Hughes, May 29

Patient advocates and medical groups on Thursday were at the state Legislative Office Building to support a bill that would curb so-called “step therapy” or “fail first” policies among health insurers.

Groups representing patients with cancer, mental illness and chronic pain appeared with lawmakers to call for a clear and concise appeals process, and limits to health insurers’ right to require that less expensive treatments be used before more expensive ones are approved.

Health insurers oppose the bill. Step therapy encourages the use of effective medication, while keeping a check on the rising cost of prescription drugs, said Paul Macielak, CEO of the New York Health Plan Association, a trade association.

“Without efforts to control rising drug costs, consumers and employers would not be able to afford prescription drug coverage,” Macielak said.

The problem with the current appeals process, said bill sponsor Assemblyman Matthew Titone, is that the insurance companies control the process. Some delay approving the proper treatment indefinitely. The bill would not eliminate step therapy, but require insurers to make their appeals process transparent and easy to follow, and limit the length of time it takes to complete, he said.

Assembly Health Committee Chair Richard Gottfried, D-Manhattan, who supports the legislation, acknowledged that step therapy can be appropriate and effective under many circumstances. These include times when doctors are not sure which remedy might work best for a particular patient and the most prudent action is to try something inexpensive first.

But he agreed with bill supporters that health insurers should not be allowed to indefinitely postpone the right treatment due to cost.

“If there are clinical reasons to choose one drug over another … it is not something that should be decided by an insurance company that is driven by saving dollars,” Gottfried said.

The bill has a companion in the Senate, sponsored by Sen. Catharine Young, a Cattaraugus County Republican. Patients who came out to oppose the practice suffered from multiple conditions whose treatment was complicated by their need to fight for the right medication, they said.

Kathleen Arnstsen sees 20 specialists and takes 36 drugs a day for lupus, kidney problems and eye disorders. She described her attempts to go through her insurers’ cumbersome appeals process to be able to take the medications recommended for her. Even finding the right forms to fill out was a challenge, she said.

“No one-size-fits-all products exist for patients like me,” Arnstsen said. “An insurance bureaucrat … has absolutely no business being on my treatment team, much less making life-altering decisions on my behalf. Period.”

People struggling with mental illness can also suffer from step-therapy policies, said Glenn Liebman, CEO of the Mental Health Association of New York State. It can take months before patients know whether a medication to treat a mental illness is effective, Liebman said. And drugs that affect brain function cannot be changed quickly; patients must be weaned off them. That means it can take a year or more for some patients to get the medication that their doctor recommends, he said.