Even when drug companies cut prices by over half, patients pay too much
by Dorothy Leone-Glasser, RN, HHC.
Pharmacy benefit managers (PBMs) are major contributors both to ballooning prescription drug prices and the lack of transparency around it.
Yet, if you’re like many Americans, there’s a good chance you’ve never heard of them.
Although they are not physicians, drug makers, insurers, or pharmacists, these companies play an outsized role in our healthcare system, making medical decisions including which prescription drugs you may take – and also how much you’ll pay for them.
Georgia Legislature’s impact on health care this year was ‘pretty big’
Insurance companies are increasingly using their power to push back against rising health care costs. And the doctors and hospitals who bill those costs increasingly say they’re going too far, meddling in medical decision making.
“Step therapy” is one such instance, where an insurance company says a patient can’t have a medicine his or her doctor prescribed right away, at least not paid for by insurance. First, the company says, the patient must try a cheaper alternative. If that doesn’t work, then the patient might step up to the one prescribed by the doctor.
A bill passed in the state Legislature this year attempts to compromise. House Bill 63 says patients can avoid step therapy with a “step therapy exception” in certain cases. Those include whether the drug “is expected to be ineffective” based on the patient’s condition and the drug’s characteristics, or if it will cause physical or mental harm to the patient.
Gov. Kemp signs bill to limit ‘Fail First' insurer decisions for chronic conditions
Chronic pain and how to treat it in the midst of the opioid epidemic has been a topic of national importance for quite some time now – and rightly so. But missing from the national debate has been the role insurance companies can, and should, play in covering non-opioid treatments for pain.
To save money, health plans often require people to “fail first” by trying and failing on therapies other than what their physicians have prescribed. This process, called step therapy, can mean weeks, months or even years without appropriate treatment. Meanwhile, people like me continue to suffer the symptoms of chronic disease and even unwanted side effects of the insurer-preferred medications.
GA lawmakers consider bill giving doctors more say in prescriptions over insurers
ATLANTA (WJBF) - The concept is basic, what you expect when you go to the doctor. Your doctor prescribes the medication that will help you get better, right?
Georgia law doesn't ban step therapy, which allows insurers to make you try older, cheaper drugs before the new ones your doctor prescribes.
"What they wanted our epileptic patients to do was to fail twice on two different kinds of medication before they would give them the medication that would keep their seizures in order. If you fail, and you're an epileptic and have seizure, you lose your drivers license for 6 months. How does a father or mother support their family or get to school? It's so ridiculous," says Rep. Sharon Cooper.
Georgia House Passes Legislation to Reform Step Therapy Insurance Practice Requiring Patients to 'Fail First'
Atlanta, GA (Feb. 15, 2019) – More than 30 Georgia patient and provider groups led by the Rx in Reach Coalition today applauded the state House of Representatives for passing House Bill 63 – legislation sponsored by Rep. Sharon Cooper (R-Marietta) to reform the insurance practice known as step therapy, which forces patients to try and fail on medications other than what their health care provider prescribes. In some cases, insurers even require step therapy when patients have already tried the insurer-preferred medications, or when those medications could cause their health to deteriorate.
House panel backs curbs on ‘step therapy’ rules for medications
When Brannen Whirledge was diagnosed with ulcerative colitis at age 4, he was put on medications that failed to help him. He suffered continual vomiting and severe stomach cramps.
Then they found a medication that worked. Brannen’s symptoms went away.
But after six months, says his mother, Melissa Whirledge, the family’s insurer told them that it would no longer cover the effective medication until “he failed on other drugs that he had already failed on.’’
The family appealed that ruling, and Brannen, now 7, has received exceptions to the drug restrictions. He is doing well, his mother says.
Georgia House Insurance Committee Unanimously Passes Legislation to Reform Step Therapy Insurance Practice
Atlanta, GA (February 13, 2019) - More than 30 Georgia patient and provider groups led by the Rx in Reach Coalition today applauded the state House Insurance Committee and its chair, Rep. Richard Smith (R-Columbus), for unanimously passing House Bill 63 -- legislation sponsored by Rep. Sharon Cooper (R-Marietta) to reform the insurance practice known as step therapy, which forces patients to try and fail on medications other than what their health care provider prescribes.
Georgia woman battles HMO's switch from insulin pens to syringes
SUWANEE, Ga. (FOX 5 Atlanta) - Carol Bolton, a Suwanee, Georgia mother of two, says her insulin KwikPen has helped her stay on top of her type 2 diabetes for more than a decade.
"There is nothing to it; it's so easy and quick," Bolton says. "You just take it out of your purse, adjust the insulin level and inject the insulin into your stomach."
But in early December, she says, she got a letter from her HMO, Kaiser Permanente of Georgia, telling Bolton she would have to switch from the insulin KwikPen back to the traditional vials and syringes.
More than 30 Patient & Physician Groups Applaud Georgia Legislation to Reform Step Therapy Insurance Practice
Atlanta, GA (Jan. 28, 2019) – More than 30 Georgia patient and provider groups led by the Rx in Reach Coalition today applauded Rep. Sharon Cooper (R-Marietta) for introducing House Bill 63 – legislation to reform the insurance practice known as step therapy, which forces patients to try and fail on medications other than what their health care provider prescribes – and in some cases, happens even when patients have already tried the insurer-preferred medications or when those medications could cause their health to deteriorate.
1 in 4 doctors say prior authorization has led to a serious adverse event
It just keeps getting worse. That’s a major finding of an AMA survey of 1,000 practicing physicians who were asked about the impact prior authorization (PA) is having on their ability to help their patients.
More than nine in 10 respondents said PA had a significant or somewhat negative clinical impact, with 28 percent reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.