Proposed state law would limit how health insurers can disrupt patients’ prescriptions

The severe repercussions of the COVID-19 pandemic have cast widespread attention on the flaws in our health care system, especially on the lack or imbalance of services to our most vulnerable communities.

One area of concern centers on a policy known as “step therapy” and how it is adversely affecting people living with chronic health conditions. In California, for example, there are millions of cases of chronic disease that include cancer, arthritis, Crohn’s disease, colitis, and mental health disease.

It’s why this year I have authored Assembly Bill 347 to reduce delays in obtaining medications and to establish a standard, transparent process.

Step therapy is a policy in which a health insurance company forces a patient to try therapies of the insurance company’s choosing — often for months — before covering the medication recommended by the patient’s health care provider. Too often the insurers don’t fully understand the specifics of a patient’s condition.

When I was an emergency room doctor, I often treated patients with multiple health conditions who were at their worst with debilitating ailments. Sometimes, I would be informed that the medication they were taking was dictated by the patient’s insurer — not the one recommended by the patient’s doctor. This would undermine the situation and cause additional health complications.

In 2015, the state took steps to address this policy. Then-Gov. Jerry Brown signed Assembly Bill 374, which helped streamline the step therapy process by providing doctors with an official form to bypass step therapy for a patient. Health plans would have within 72 hours to respond, aligning the time frames with prior authorization requests.

My bill, AB 347, would build on the previous legislation to improve timely access to medication for our most vulnerable patients. In 2016, for example, a survey conducted by the Arthritis Foundation found that 700 out of 1,400 patients reported trying two or more treatments prior to obtaining the one their doctor originally recommended.

In addition, this approach to treatment may cause financial burdens. A study released by Avalere indicated that patients living with Crohn’s disease averaged higher out-of-pocket costs due to required insurer step therapy protocols. On average, a patient paid a 37 percent higher out-of-pocket costs, compared to a patient who didn’t go through step therapy. In actual dollars, the study said that translated to $186,000 in annual costs for a patient going through step therapy, compared to $136,000 in annual expenses for the patient who didn’t.

AB 347 would require these measures:

• Create standard exceptions to step therapy to be used by all payers;
• Allow for clinical peer-to-peer review appeals by a health care professional in the same profession, or similar specialty, as the doctor who typically manages the patient’s medical condition, procedures, or treatment under review;
• Require that a payer send an approval or denial of a step therapy exception request, or a prior authorization request, rather than just submitting a response within specified time frames; and
• Increase transparency by requiring payers to annually report information on the number of step therapy and prior authorization requests and denials they have submitted to the California Department of Managed Health Care and the California Department of Insurance.

AB 347 recently earned overwhelming support from the Assembly Health Committee. As this bill makes its way through the legislative process this year, I urge my colleagues to continue supporting efforts that ensure all patients will receive the best treatments in an expedited time frame.

This story was originally published May 19, 2021 at 11:01 AM.