Putting Patients Back at the Center of Sensible Health Care Policy

Guest Opinion

by Assemblyman Jim Frazier, (D-Oakley)

Many Californians are facing restricted access to health care due to dangerous and expensive health insurer policies that prevent patients from getting timely and effective treatments.

Some California health insurers have implemented a series of draconian restrictions in the name of cost containment that place health insurers squarely in the middle of the physician-patient relationship.

One such barrier is a policy known as “step therapy” or “fail first.” Step therapy requires that patients try and fail on up to five older, less effective medications before the insurer will cover the treatment originally prescribed by the doctor. Under this policy, patients are often forced to try and fail on these treatments even when they have already tried them in the past, and even when their doctor knows the treatments will not work.

Insurers enact restrictions like step therapy under the guise of cost containment, but the practical impact is that California patients – many of whom suffer from chronic conditions or debilitating pain or mental illness – will unnecessarily go for days, weeks, or months without their doctor-prescribed treatment. In short, step therapy hurts Californians, prolongs ineffective treatment, and prevents patients from immediately starting the treatments their doctors think are best.

While it would be tempting to dismiss step therapy as a mild inconvenience for patients, the unnecessary burden of step therapy has very real health and economic consequences. Delays in treatment can exacerbate health problems and often allow manageable conditions to deteriorate into more serious problems or disease.

Imagine, as an example, a single mother living with rheumatoid arthritis in Contra Costa County. When she is denied access to care, it is not only her physical condition that suffers. Every unnecessary visit to the doctor or pharmacist requires out-of-pocket co-pays.  Unnecessary medical appointments can also lead to additional days of missed work, which in turn results in loss of wages, as well as drives up costs for her employer through lost productivity and increased insurance premiums.

A recent analysis from the California Health Benefits Review Program (CHBRP) found that those living with and managing mental illness are particularly susceptible to the negative effects of step therapy protocols. CHBRP found that, when faced with the additional barriers to care created by step therapy, mental health patients are more likely to stop taking their medication. When a person coping with mental illness does not stay on his or her doctor-prescribed treatment regimes, it can lead to dire consequences, including hospitalizations, suicide attempts, and even imprisonment. In addition to the serious health consequences, unnecessary emergency room visits and increased imprisonment drives up the direct costs to the California health care system and all California taxpayers.

Advancements in science and medicine have yielded new treatments that can more effectively treat patients and speed up their recovery. Unfortunately, Californians will only be able to access these treatments when we require the insurance companies to limit their step therapy practices. Patients must not be asked to bear the unnecessary physical and emotional burdens of step therapy.

In an effort to address this issue, I have sponsored Assembly Bill 889, which directly addresses step therapy and the burden it places on patients. AB 889 is common-sense patient-protection legislation that will limit step therapy for all medicines to no more than two steps. In addition, it will prohibit a plan from requiring a patient to go through step therapy again if the patient went through it when covered by another plan.

In this critical era of health care cost containment, AB 889 preserves step therapy as a tool for California insurers, but also keeps decisions about how best to treat patients in the hands of their doctors – a win-win for the California health care delivery system. AB 889 will also help lower the long-term costs of health care, as patients can be appropriately treated for their conditions and not be forced to try outdated medications.

California legislators must take action now to ensure that all patients can access the treatments their doctors think are best. Our constituents are frustrated with current restrictions and it’s important that decisions about how to treat patients reside with doctors, not insurance companies.

Frazier represents the 11th Assembly District of California, which includes Antioch. To contact him, visit http://asmdc.org/members/a11/

One Comment to “Putting Patients Back at the Center of Sensible Health Care Policy”

  1. Kenji Freitas says:

    Just curious, will this bill also address the push by the pharmaceutical industry to prescribe certain drugs first because of the profit, rather than try what is best for the patient? I know different HMOs have preferred medication lists, which are influenced by them.

Leave a Reply