Lawmakers and health system reformers are moving to end a practice known as "step therapy," a cost containment tool promoted by the insurance industry that requires doctors to treat patients first with less expensive drugs, and then, if those don't work, to move on to more costly medications. Advocates say the current system denies patients the medication their doctors want them to take.
The state Senate unanimously passed a bill last summer limiting insurers' ability to insist on lower cost medication. It's unclear how House leaders will greet Wednesday's initiative.
Sen. Julian Cyr says the step therapy policy delays the care dictated by doctors.
"Step therapy doesn't work. It prevents sick people from receiving medical treatments they need and other medical providers feel are best suited for them, only for the purpose of saving costs for payers," Cyr said Wednesday on a Zoom call with supporters urging House lawmakers to take up the bill.
The bill never got a vote in the House last session — representatives say they ran out of time — but proponents are hopeful House leaders will make it a priority before the end of next year.
Rep. Jeff Roy says he knows of countless patients forced to take the lower cost drugs their insurance company wants instead of what their doctor recommends.
"It's an insurance practice... making patients try and fail on insurer-preferred drugs before getting access to the drug their doctor knew would have the best chance of working," Roy said.
The reason for the step therapy policy is cost, a cost that all ratepayers end up footing as the price of pharmaceuticals continues to climb.
Massachusetts Association of Health Plans president Lora Pellegrini wrote in a statement that medical management tools like step therapy ensure safety, provide value and help control growing health care costs.
"Step therapy encourages prescribers to use prescription drugs that are safe, clinically appropriate, and cost effective before using drugs that could pose safety concerns or clinical concerns or have higher costs and is used in limited circumstances," Pellegrini wrote. Pellegrini's group, which represents the state's leading health insurance companies, supports a transitional period away from step therapy to ensure continuity of care before major policy changes are made.
Advocates hope to get the bill through the House this session, but concerns about the ever-growing cost of care in Massachusetts may slow things down.
