A one-size-fits-all approach to health care is dangerous for Californians.
Just ask Wesley Mizutani, MD, a rheumatologist in Huntington Beach.
During a recent online legislative briefing hosted by the Alliance for Patient Access and the California Chronic Care Coalition, Dr. Mizutani described seeing patients endure step therapy. The approach requires patients to try and fail a drug preferred by the insurance company before getting the medication their physician prescribed.
One patient with rheumatoid arthritis saw her condition decline, Dr. Mizutani recalled, leaving the woman wheelchair dependent. She also suffered permanent damage to her elbow joints.
The story resonated with arthritis patient and advocate Tiffany Westrich-Robertson, who has her own step therapy story. When Westrich-Robertson changed insurance companies, she was forced off of the biologic medication that kept her condition well managed. Her new health plan wouldn’t accept that Westrich-Robertson had already tried the insurer-preferred medication and found it ineffective. The health plan forced her to try the medication yet again. Through her work with the International Foundation for Autoimmune and Autoinflammatory Arthritis, Westrich-Robertson has heard of many patients who have had a similar experience.
The good news? More than 35 legislators, staff and advocates attended the web-based briefing to learn about how step therapy affects patients. They also heard why advocates want changes like those proposed in Assembly Bill 347.
The bill requires health plans to “expeditiously” provide exceptions to step therapy in certain situations. Health plans would also have to report on requests for step therapy and prior authorization exceptions to the Department of Managed Health Care or the Department of Insurance. Patient stories like those shared in the briefing demonstrate why this policy change is needed.
The bill was introduced by a physician member of the California State Assembly, Joaquin Arambula, MD.
Improving Drug Formulary Transparency
Access barriers aren’t the only health policy priority for Californians. Advocates are also eager to address lack of formula transparency, which can affect patients’ out-of-pocket costs.
Professor of Pharmacy Shane Desselle, PhD, spoke about the effect of “sticker shock” on patients. Not knowing the cost of a prescription until they reach the pharmacy counter can lead patients to abandon their medication. High out-of-pocket costs also lead to improper medication use – when patients skip doses or don’t take the full dose – to make it last longer.
Patrick McGill, MD, of Community Health Network, explained the benefits of improving formulary transparency. As a former family medicine physician, Dr. Gill knows first-hand that patients are less likely to take medications they can’t afford, even if they need them. But physicians lack data about which medications are covered by different health plans and what the out-of-pocket cost is to the patient.
California Assembly Bill 752 aims to overcome that data gap. The bill requires health plans to cover medically necessary prescription drugs and limits cost-sharing on those drugs. It also requires plans to disclose cost information to patients and their health care providers. The bill was introduced by California State Assembly member Adrin Nazarian, and is strongly supported by the California Chronic Care Coalition as well as other advocacy organizations.
More legislators and staff now understand that reforms like these can help put the state of California back on the path toward patient-centered care.