Texas Rheumatologists Push for Passage of Step Therapy Reforms

On May 25, with Gov. Greg Abbott’s signing of Senate Bill 680, Texas became the fourth state this year to increase protection for patients subject to insurers’ step therapy protocols. The State of Texas Association of Rheumatologists (STAR) joined with 35 other professional societies and patient advocacy organizations in urging passage of S.B. 680. The passage of the bill entailed a lengthy process, and enjoyed “widespread bipartisan support,” according to Rep. Greg J. Bonnen, MD (R, District 24), which includes part of Galveston County. Rep. Bonnen authored House Bill 1464, the tandem bill in the House to Sen. Kelly Hancock’s Senate bill.

Rep. Greg J. Bonnen, MD (R, District 24).

According to Rodolfo “Rudy” Molina, MD, president of STAR and a rheumatologist in private practice with Arthritis Associates PA of San Antonio, the state association received notification of the pending legislation in early February. Simone Nichols-Segers of the National Multiple Sclerosis Society, and Hayley McCloud, the ACR state government representative, urged STAR to officially join the consortium of organizations supporting the bill. Dr. Molina and Sharad Lakhanpal, MD, FACR, FACP, ACR president and clinical professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas, contacted their own district representatives to inform them of their support for the bill and urged association members to do the same.

Sharad Lakhanpal, MD, FACR, FACP, ACR president.

Cost Vs. Patient Benefit
S.B. 680 and H.B. 1464 were drafted to address concerns about insurers’ overuse of step therapy (also called fail-first) protocols, explains Dr. Bonnen—namely that protocols were being driven more by commercial concerns than by scientific evidence. “Patients were encountering scenarios where they’d been on a medication and had been stable for a long period of time—in some instances for years—and then their insurer would change the protocol and potentially force them to change their medicine.”

Dr. Lakhanpal, like many rheumatologists, is all too familiar with the complications and dangers of fail-first therapy. “We know that denying treatment for a patient with inflammatory arthritis for four to six months can cause irreversible joint damage. We have to always think, ‘What is best for the patient?’”

As insurers have increased their use of step therapy protocols to control the cost of expensive drugs, more advocacy organizations have raised concerns about the ethics of the practice. The ACR and other professional medical societies have urged reform so that authorization of medications is based on clinical criteria.

Provisions of the Texas Law
The Texas law reforms, but does not ban, step therapy. This legislation seeks to ensure that an insurer’s process for requesting a step therapy override is transparent and available to the provider and the patient. It creates a process to allow automatic protections from step therapy requirements when patient safety is at risk. These protections apply even if patients have their health insurance changed to a different company or if the company’s formulary changes at contract renewal. The law also allows physicians to request a step therapy override based on the individual patient’s history and that such requests be answered within 72 hours (or 24 hours in special circumstances). The law goes into effect Sept. 1.

Lessons Learned
When asked about the lessons learned regarding passage of S.B. 680, Dr. Lakhanpal says, “when you have physicians in every city and county start writing letters, the momentum builds. The grassroots movement activities of contacting our representatives, I think, played a major role.”

It’s important, he and Dr. Molina agree, to engage with one’s legislative representatives. Dr. Molina makes it a practice to hold regular meetings with Texas state representatives and “talk with them about the issues rheumatologists face. Few legislators have a medical background or experience taking care of patients. When they understand the issue, they can act on it.”

Dr. Lakhanpal has been a steadfast supporter of step therapy reform in Texas and across the country. He has promoted the success of the ACR in shaping step therapy reform in fifteen states. Sharing success stories helps build momentum. “Hopefully, other states will follow, because the most important thing is to do the right thing for our patients.” If you are interested in pursuing this type of legislation in your state, contact Hayley McCloud, ACR Sr. Manager of State Affairs.

Gretchen Henkel is a medical journalist based in California.