AUGUSTA — Advocates and opponents of a bill that would regulate “step therapy” used for prescription medications made their case to the Legislature’s health coverage committee on Thursday, with advocates arguing that patients should be better protected and the insurance industry contending that the protocols save money.
Step therapy – also known as “fail first” – requires that patients try certain, usually less expensive, drugs before moving to more costly medications that treat the same condition. The policies help control costs, but patient advocate groups have argued that in some cases the policies can be harmful to patients by denying them medication that works best for them. In some cases, they have to repeatedly go through step therapy.
“My growing brain is more important than saving money,” said Hannah Mitschele, 11, a sixth-grader at Memorial Middle School in South Portland. Hannah has epilepsy, and has frequently switched medications to control the condition. “I am not a guinea pig. I am Hannah, and I am important and so is my medicine.”
The Health Coverage, Insurance and Financial Services Committee heard testimony on the bill Thursday, and will discuss the proposal further in the coming weeks.
If the bill – sponsored by Rep. Charlotte Warren, D-Hallowell – becomes law, Maine would join 22 states that have similar statutes on the books. The bill would not ban step therapy, but establish rules, such as setting up a process for doctors to override insurance company decisions on medications, and ensure that fail-first policies are transparent. The measure would also limit other practices, such as making patients go through the fail-first method repeatedly.
Andrew MacLean, interim CEO of the Maine Medical Association, which represents doctors before the Legislature, said the association supports the bill to establish “reasonable” guidelines surrounding step therapy.
The American Cancer Society, National Multiple Sclerosis Society and others supported the bill, but those representing the health insurance industry and pharmacy benefit managers opposed it.
Katherine Pelletreau, executive director of the Maine Association of Health Plans, representing the insurance industry, said the bill would favor “costlier, but no more therapeutically effective, brand name drugs.”
“Step therapy protocols protect patients both financially and physically,” Pelletreau said. “Often doctors prescribe the ‘newest’ drugs, even when those drugs lack clinical data of their value.”
But H. Lori Schnieders, 69, of Machias said she has to try other treatments first every year before her insurance company will approve the more expensive immune therapy that has proved to work for her rheumatoid arthritis.
“I’m on a good regimen of medications now,” said Schnieders, a professor at the University of Maine at Machias. “It’s important to keep people like me walking, working and paying taxes.”
Margaret Mitschele, Hannah’s mother, said epilepsy requires specialized medications, and while they haven’t been told to go through “step therapy” yet, her daughter has been on 14 different medications in 10 years. She said they live in fear of being told that they must try other drugs first that would be ineffective and Hannah would have seizures.
“We’ve been very fortunate, but I’m fearing that one January we could get that letter from the insurance company telling us that we have to try these other drugs,” Mitschele said. “We shouldn’t have to worry about it. There should be safeguards in place.”
Warren said the bill strikes a balance by not outright banning step therapy, but establishing rules to prevent abuse of patients.
“This is common-sense legislation that seeks to improve the current step therapy process, while striking a fair balance between cost containment and the health of Maine patients,” Warren said.
Joe Lawlor can be contacted at 791-6376 or at:
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