BOSTON (SHNS) – The House and Senate unanimously agreed this summer to restrict the practice in which some patients are made to try and fail on insurance-preferred treatments before their insurer will approve a more expensive option prescribed by a doctor. Now, it appears lawmakers have hashed out a final version of their patient protection bill.
The so-called step therapy bill emerged Thursday from a nearly three-month stay in the House Bills In Third Reading Committee, and before adjourning for the weekend, the House adopted a Rep. John Lawn amendment (H 5358) to the Senate bill (S 3056) and sent it back to the Senate for its consideration.
House, Senate and advocacy community officials interviewed by the News Service on Thursday suggested a compromise bill may soon reach Gov. Charlie Baker.
Lawn’s amendment dealt with the number of days allotted for appeals under the bill, and a source aligned with a coalition of more than 50 patient groups that support the bill said the branches are now in agreement on the appeals day issue.
The coalition has advocated for the timeline for insurers to process step therapy exception requests and appeals to be 72 hours generally and 24 hours in the case of an emergency “if additional delay would result in significant risk to the insured’s health or well-being.”
The Lawn amendment calls for appeals to be processed in three business days or 24 hours in emergencies.
The Senate adjourned for the weekend Thursday without acting on the amended bill, but a key senator suggested the branches are aligned.
“We’re very comfortable with the compromise,” Sen. Cindy Friedman, co-chair of the Health Care Financing Committee, told the News Service after session on Thursday. “We worked out some of what I think are minor issues very easily. And I think the Senate is — we’re certainly comfortable with it.”
Under the House bill approved in June, insurers would get up to three business days to weigh requests and must respond by the “next business day” in emergencies. The Senate bill approved in late July set those thresholds at 72 hours and 24 hours, a distinction that could result in different timelines if weekends or non-business days come into play.
Lawn, co-chair of Health Care Financing, told the News Service the amendment was a “compromise with the Senate” on appeals days.
“The amendment perfects the bill so it’s a clearer process for patients and carriers,” he said. “The amendment shortens the time in emergencies on exemption requests. This bill will help patients in Massachusetts receive timely access to the drugs they need so they can live longer and happier lives.”
During debate on the bill in June, Lawn said people most affected by step therapy include those with chronic migraines, Crohn’s disease, psoriasis, ulcerative colitis, arthritis, multiple sclerosis and hepatitis C.
“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 in June. “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.”
Marc Hymovitz, one of the most prominent advocates for step therapy reforms, has said appeals day allowances are critical.
“If you picture a person having an epileptic seizure who goes into the hospital on a Friday night of a long weekend, the next business day isn’t until Tuesday. Even on a normal weekend, the next business day isn’t until Monday,” Hymovitz, who works as government relations director in Massachusetts for the American Cancer Society Cancer Action Network, said in August. “A patient suffering a seizure or an asthma attack shouldn’t have to wait until Tuesday to get an answer from their insurer whether or not they can take the medication that their doctor feels is best for their condition.”
On Thursday afternoon, Hymovitz said he hoped a bill could reach the governor next week.
“Everything we’ve heard from the House and Senate is they want to get this done,” he said.
Hymovitz said 34 other states have some form of step therapy restrictions.
“This is a really good patient protection bill,” he said.
(Sam Doran and Sam Drysdale contributed reporting.)