Advocates Refuse to ‘Fail First’

Have you ever gone to the pharmacy to pick up a medication and were told “I’m sorry, we cannot fill your prescription because of your insurance?” As a pharmacist, I’ll say that it’s a common conversation we have that often causes stress, confusion and an overall daunting health care experience for people whether the medication is ultimately covered or not.

Behind the scenes at the pharmacy, we must contact the doctor (which is no easy feat itself) and relay the denial message from the insurance plan which typically involves submitting paperwork for either a prior authorization, a quantity limit or step therapy, just to name a few. This seemingly easy process takes time, effort and patience by both sides and could take days, weeks or even months to resolve.

Insurance plans use step therapy to save money while, hypothetically, still providing patients with safe and effective treatments. Unfortunately, in practice too many people fail repeatedly people on insurer-preferred medications before the insurer will cover the originally prescribed treatment. The potential consequences? Reduced medication adherence, treatment delays and worse health outcomes.

Health care is personal. Patients should be able to choose their treatment plan with their providers with the expectation—within reason—that it will be honored. While step therapy fulfills an important role—lowered costs– we can still improve it while preserving the patient-provider relationship and reducing the stress and confusion that people face at the pharmacy counter.

Health care is personal. Patients should be able to choose their treatment plan with their providers with the expectation—within reason—that it will be honored.

On January 23, NPAF led the Virginia Step Therapy Reform Coalition in an advocacy day, bringing patients, their families and providers before their state senators and delegates. We asked the Virginia General Assembly to support SB 574 and HB 386, which would establish certain clinical scenarios or exceptions in which people may seamlessly continue their prescribed treatment. The legislation also requires insurance plans to clearly outline the exceptions process for patients and providers and to grant exceptions in a timely fashion to prevent treatment delays. Seventeen states, including West Virginia and Maryland, have enacted similar legislation, while advocates have successfully built support for step therapy reform in many other states.

During our advocacy day, advocates met with each member of the committees of jurisdiction: the Senate Commerce and Labor Committee, Senate Finance Committee and the House Commerce and Labor Subcommittee #1. During these meetings, advocates debunked the myth that this legislation eliminates step therapy; instead, SB 574 and HB 386 will enhance patient protections and make step therapy work better for people with serious, chronic or life-threatening conditions. Overall, our advocacy day generated over 1000 impressions on social media.

Throughout the day, I thought of my own family and how my father, a two-time cancer survivor, has truly been through everything to find the right treatments, not just directly for his cancer but for all the other ailments that come with it. Most recently, he was diagnosed with osteoarthritis of the knee, a common illness that can be managed with various injectable treatments. He, with his doctor, settled on a particular treatment but his insurer denied coverage. Instead, he first had to take a lower-cost treatment for six months, despite unsuccessfully trying a course of that drug years ago, followed by several other “steps”. After two years, he still has not received the most promising treatment and now fears the prospect of knee replacement surgery. At this point, my father’s morale is lower than ever before and it pains all of us to see him feeling hopeless.

So many people have similar stories and nobody could forget the frustration and confusion. The good news is that you can make a difference. Lawmakers need to hear your story about how step therapy restrictions have affected you or someone you love. Your story could be the one that changes minds and helps a bill get passed.

Ultimately, SB 574 and HB 386 did not pass in Virginia—yet. But with the help of patient advocates, we educated lawmakers about the unintended consequences of step therapy and how this important legislation would improve the process for patients and their health care team. We even received feedback that our efforts put significant pressure on the bills’ opponents – which is a testament to advocates’ hard work and powerful stories. We are hopeful that the momentum gained this year will bring us to victory next session.

The next time a patient comes to my pharmacy counter stressing over a step therapy issue, I’ll think of our advocacy day and encourage them to share their story. I’ll also do everything I can to help them advocate for themselves and loved ones because patient voices matter.