As the practice of step therapy grows more pervasive throughout the insurance industry, the protocols become increasingly confusing to navigate. Steps vary from insurer to insurer based on plan type, and formulary differences are too often based on economic incentives rather than outcome-based medicine. Patients are often left hanging in the balance while physicians’ offices help them navigate the step therapy process.
Fortunately, states are now stepping in to help bring some uniformity to the insurance market. Twenty-four states have now passed some variation of step therapy reform. If there’s one word to characterize step therapy practices nationwide, it would be “variable.” Even though states pass reform, physicians may not even notice a difference. Medicare and Employee Retirement Income Security Act (ERISA) based plans are exempt from state reforms because states cannot preempt the federal laws that govern these programs. That is why it is important for you to contact your Congress members and Senators to encourage them to support a federal step therapy bill. You can easily do this through the ACR’s Legislative Action Center.
Only Connecticut, Kansas, Louisiana, New Mexico, New York and Wisconsin have included Medicaid plans in their step therapy reform packages. What about the other components of reform? Here is a brief rundown of where the states stand and how to navigate your state’s step therapy framework.
24-Hour Emergency Response to Override Request
The 24-hour emergency response to an override request is critically important to patients who need rapid treatment. More timely interventions can mean better outcomes for patients, but that requires state policy that recognizes that fact and respects the physician’s right to choose the best drug for the patient.
Nationwide step therapy practices are variable. Only 10 states currently have a 24-hour emergency response to override requirement. Illinois, Indiana, Kansas, New Mexico, New York, Texas and Virginia currently have this provision effective. The Georgia, Oklahoma and Wisconsin provisions will go into effect on Jan. 1, 2020. Washington’s provision will go into effect in January 2021.
Also of note, Ohio has a 48-hour emergency response requirement that will go into effect on Jan. 1, 2020, while Iowa and Minnesota both have a 72-hour emergency response requirement. Although these offer some protections for patients, these are not ideal timelines for emergency cases.
72-Hour or Better Response to General Override Requests
The 72-hour response requirement for general override requests is critical for getting all patients access to the care they deserve. Right now, only 13 states have this requirement. Arkansas, California, Illinois, Indiana, Kansas, New Mexico, New York, Texas and Virginia all have the 72-hour response requirement in effect. Georgia, Oklahoma, and Wisconsin will have this provision effective starting Jan. 1, 2020, while Washington’s will go into effect in January 2021.
Lagging again are Iowa and Minnesota, with a five-day requirement, while Ohio has a 10-day requirement that will go into effect on Jan. 1, 2020. While these response times are far from desirable, they still provide some timeline, even though they will still result in delays in care for patients.
Override for Previously Failed Steps
One of the most important provisions of any step therapy bill is the inclusion of an automatic exception for a patient who has previously failed a step. This protects patients from having to repeat medications that have already proven to be ineffective for them. Twenty-one states currently have this exception in their state laws, with Georgia, Ohio and Wisconsin’s protections becoming effective on Jan. 1, 2020. Washington state’s will again go into effect in January 2021.
Override for Contraindication
Of all the override exceptions, this may seem like the most obvious: A patient should not take a drug that would likely cause them harm. While this may seem like a common-sense exception, its inclusion in step therapy laws is far from universal. Twenty states currently have an exception for contraindications. Georgia, Ohio, Oklahoma and Wisconsin’s provisions will go into effect in January 2020, while Washington’s will go into effect in January 2021.
Override for Stable Patients
Again, this may seem like a common-sense override exception, but only 15 states currently have overrides for stable patients. This is a particularly important exception for patients who are stable on a biologic. As you likely know, many patients who are stable on a biologic may not respond the same if they are switched to a different drug and then try to switch back to the original biologic. Although we cannot fully explain this phenomenon, we do know how to prevent it: Do not require stable patients to switch medications.
Your Role in Changing the Conversation
As a physician, you are not only a trusted resource for your patients, you are also capable of being a trusted resource for your local legislator. State legislators often depend on local experts from their districts for advice on complex issues like health policy. It is important for you to get to know your local legislative delegation where they live and work.
District meetings are one of the best places to establish meaningful and impactful relationships with legislators. You may often find yourself meeting them at a local coffee shop or restaurant instead of in an office. This kind of personal meeting has proven time and time again to be more effective than capitol office meetings. The legislator may be more relaxed and receptive, and may have more time than during a typical office meeting.
It is also important to get your patients involved. Encourage them to not only be active in their own care, but to be their own advocate. When doctors and patients come together, there are few policy goals that cannot be achieved. The ACR is here to help, and we are working on developing education materials to help patients better understand these complex issues and how they impact their daily lives. We have also developed a short guide to step therapy that shows what each state has included in their step therapy laws, with links to insurance department complaint forms, which can be used when payers are not acting in accordance with the law.
Finally, if there is any specific way that we can help you, or if you have suggestions for what we can do better, email our advocacy team at [email protected]. We are a resource for you, so if you have any questions, comments or suggestions we would love to hear them.
Joseph Cantrell, JD, is the senior manager of state affairs for the ACR.
