House Votes To Restrict Insurers' Power Over Prescriptions

Above image courtesy of www.patientrising.org, an advocacy organization

Representatives pointed to "compelling and emotional testimony" from patients who have been made to try and fail on insurance-preferred treatments before their insurer would approve the more expensive treatment prescribed by a doctor as they voted unanimously Wednesday to put restrictions on the practice known as step therapy.

The bipartisan vote was 153-0 to pass a bill (H 4929) that does not ban step therapy but seeks to lay out a "consistent and transparent manner" in which public and private insurance providers could use the practice when medically appropriate, Rep. John Lawn of Watertown, the House's chair of the Health Care Financing Committee, said. He said people who have chronic migraines, Crohn's disease, psoriasis, ulcerative colitis, arthritis, multiple sclerosis and hepatitis C are among those most affected by step therapy.

"This bill requires insurers to make exceptions to step therapy, to make timely decisions on those exceptions, to allow for an appeals process, and to report annually to the Division of Insurance on those exceptions. House bill 4929 also allows for exceptions to step therapy on four conditions: If the treatment will harm the patient, if the treatment will be ineffective, if the patient has already tried and failed the treatment, and if the patient is already stable on a different treatment," Lawn said. "This legislation -- I want to be clear in this -- does not ban step therapy. Insurers may still use step therapy to contain costs. It will, however, prevent cost savings at the expense of patients' health."

There was no debate in the House on the bill and the only amendment filed was withdrawn without comment. But representatives who have sponsored step therapy bills took to the podium to share stories about how constituents have been made to watch as their disease or condition gets worse before their insurance would cover the cost of a treatment that their doctor thinks would help.

"Take for example, Anna, who's been living with juvenile arthritis since she was 11. The disease has had serious and long-term consequences for Anna's health that have involved multiple surgeries. Anna told me how she has been made to go through step therapy a whopping 17 times, including in some cases for the same drug she had failed on before," Rep. Jeff Roy of Franklin said. "It's shameful and it flies in the face of the medical objective to first do no harm."

A coalition of more than 50 patient groups that has been working to pass step therapy legislation said Wednesday afternoon that it is excited by the House's vote.

"We need to reform step therapy protocols so that patients have access to the medications they need that their physician has prescribed to help them. The current process now forces patients to wait months and sadly years to access the medication that is right for them," Marc Hymovitz, government relations director in Massachusetts for coalition leader the American Cancer Society Cancer Action Network, said. "Under these 'fail first' policies, patients are currently required to try and fail one or more medications specified by their insurance company -- not their physician -- to treat their health condition."

Rep. Marjorie Decker of Cambridge said the issue of step therapy was brought to her attention by a constituent who wanted her to meet a single mother who could not get the medication her doctor called for because of her insurance company.

"Every day, someone is made to suffer when they're not listened to, when their doctor is not listened to. And in talking to her, it really hit me to think about what it meant for this single mom to unnecessarily suffer because the insurance industry would not listen to her or her doctor," Decker said. "It's outrageous."

The Senate unanimously passed a step therapy bill in July 2020, but it did not get a House vote before the end of that legislative session. Senators have not signaled plans for a vote on the current bill but the makeup of the branch has not changed significantly since the 2020 vote.

The House on Wednesday also passed a bill (H 4931) relative to pesticide use in Massachusetts. Rep. James Hawkins of Attleboro said the bill was written in such a way that "there's no burden to anybody involved" but will still "significantly reduce the use of these second generation anticoagulant rodenticides" through awareness and reporting requirements.

"The issue is when pest control companies use the bait boxes, the rats eat this poisonous anticoagulant -- which means they bleed to death -- and they leave the bait box and their predators eat them. So if an owl eats this poison rat, the owl will die and in the meantime, the owl could have eaten five- or six-hundred rats. And worse, sometimes the owl will feed it to their family, so the babies die also. And it's not just owls, we lost two bald eagles on the Charles River last year, family pets are involved," Hawkins said. "It's a pretty horrible situation."

It was also a unanimous vote of the House on Wednesday to fund a $56 million legal settlement related to the COVID-19 outbreak that took the lives of at least 76 veterans at the Holyoke Soldiers' Home in 2020 (H 4932). The bill's next stop is the Senate Committee on Ways and Means.

The Baker administration agreed to the settlement in May and a federal judge approved it earlier this month. The terms of the settlement would cover veterans who lived at the state-run Holyoke home at any point between March 1, 2020 and June 23, 2020 and who became ill or died from COVID during that period. Estates of deceased veterans would receive at least $400,000 and veterans who contracted COVID but did not die would receive at least $10,000, the governor's office said when it announced the agreement.

Former U.S. Attorney Donald Stern is expected to serve as the settlement claims administrator and will process awards to claimants based on his review of each individual circumstance. In March, the House and Senate appointed a conference committee to reconcile differences between the soldiers' home reform bills (H 4441 / S 2761) that each branch has passed.