When the story broke last month that a former medical director for insurance giant Aetna never reviewed patients’ medical records before denying care, the news media and insurance regulators seemed shocked. But for the millions of Americans – and thousands of Georgians – who are fighting for access to treatment, the news was likely just more proof of what they already knew: Our health insurance system is sorely in need of reform.
Georgia has an opportunity this legislative session to cut through the secretive red tape surrounding insurance practices and ensure that the sickest and most vulnerable among us have the care they need.
House Bill 519, which unanimously passed the state House this session and is also pending as Senate Bill 325, would limit step therapy – also known as “fail first” – protocols, whereby patients are forced by their insurance providers to try and fail on a series of treatments before they can obtain the medication prescribed by their physician.
As we know from the Aetna admission, insurers might not even look at patient records before denying care or forcing patients through the step therapy process.
Even so, the legislation is targeted to limit step therapy and fail-first protocols in only certain critical situations, while still allowing insurers to use step therapy and require generics when doing so will not negatively impact patients.
By creating a basic framework to exempt patients from step therapy protocols and establishing a transparent process for health care providers to request exceptions, the legislation guards against what happened at Aetna. It puts the power of care back into the hands of the patients’ physicians, who actually review their patients’ records and know what is best for their health.
If you need more proof that Georgia should enact legislation to limit step therapy, look no further than the story of Hunter Pruitt, an Atlanta teenager whom I have known for years.
At age 5, Hunter was diagnosed with juvenile idiopathic arthritis – the most common type of arthritis in children, in which the immune system mistakenly attacks the body’s tissues, causing inflammation in joints and potentially harming other areas and organs of the body. Hunter experienced painful, swollen joints, fever and fatigue. Hunter’s physician prescribed a biologic to ease the pain and joint destruction, but Hunter’s family insurance plan denied coverage, stating that he had to go through step therapy for several months and “fail first” on another drug before they would consider approving the much-needed biologic.
When Hunter reached the insurance plan’s requirement, the insurer finally approved coverage for the biologic the rheumatologists originally prescribed. But the 14-month wait for Hunter to get on the biologic medicine caused him to remain in intractable pain and miss months of school. It also resulted in joint damage that required arthritis surgery on both knees to enable him to walk again.
Had the reforms proposed in this year’s step therapy legislation been law at that time, Hunter’s physician could have swiftly circumvented the insurance company’s dangerous step therapy protocol and spared him a lot of pain and – potentially – surgery. Hunter’s story is just one of many instances here in Georgia in which step therapy is causing children and adults to suffer, complicating their already devastating symptoms, and causing costly medical interventions.
It’s time to take step therapy in the right direction and enact House Bill 519/Senate Bill 325.
Dorothy Leone Glasser is executive director of Advocates for Responsible Care, a nonprofit dedicated to ensuring full access to medical care for all Georgians.