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Are State Protections Protecting Patients?

Some insurers aren’t complying with state laws meant to protect patients from red tape and health plan delay tactics.  Just ask a doctor.

Health care providers say that regulators could do more to enforce commonsense limits on prior authorization and step therapy, according to a new series of reports from the Aimed Alliance.  The organization surveyed hundreds of health care providers in Illinois, Texas and New York.  The states are among those where advocates and lawmakers have joined forces in recent years to better protect patients’ access to prescribed medicine.  

But the Aimed Alliance’s “Utilization Mismanagement” reports: 

In Illinois:

  • 40% of survey respondents say changes to state law have not made a significant difference in whether health plans approve a step therapy exception request 
  • 33% say health plans are requiring prior authorization in medical emergencies, even though state law prohibits this.

In Texas

  • 40% say health plans are requiring patients to try and fail on the same medication more than once, even though Texas law prohibits this
  • Only eight percent say health plans meet deadlines for acting on prior authorization requests “every time.”

In New York:

  • 41% of respondents say that insurers “occasionally” or “almost never” respond to step therapy exception requests within the legal time limit 
  • 43% say the frequency of prior authorization denials has not changed.

Granted, the findings are not wholly bad.  In New York, for example, about 40% of responding health care providers say that new protections are improving patients’ access to medications.  But the survey suggests that patients and providers’ hard-won legislative victories aren’t helping patients as much – or as often – as they should.  And for advocates and legislators, that’s a bitter pill to swallow.

In the last few years, statehouses have led the way on safeguarding patients’ health – and the physician-patient relationship – from insurers’ profit-boosting measures.  State protections like those in New York, Illinois and Texas aimed to put commonsense limits on step therapy and prior authorization, as well as on non-medical switching – where health plans protect their profits by pushing stable patients to a cheaper medicine.  The reforms emboldened and encouraged advocates committed to patients’ rights and patient-centered care.

But to make those protections a reality, states now need to “heighten their monitoring and enforcement,” an Aimed Alliance spokesperson summarized.  As the survey suggests, health care providers agree.

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