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Insurer Practices Impacting Healthcare Access


WHEREAS, the Patient Protection and Affordable Care Act (PPACA) has significantly increased access to affordable healthcare to millions of Americans; however, many insurance companies continue engaging in practices that are burdening physicians and newly insured individuals. Many of these cost cutting practices can interfere with access to quality and effective healthcare for persons with chronic medical conditions; and

WHEREAS, many within the insured population may be unfamiliar with the specifics of their insurance policies, which makes them vulnerable when insurance companies carry out these practices in their efforts to maximize profits.

WHEREAS, one such practice is step therapy, a method used by insurers to limit how much they spend covering patients’ medicines. Under step therapy, patients are prescribed one or more medicines, including off-label medicines in some instances, chosen by their insurer – usually based on financial consideration – before coverage is granted for the drug prescribed by the patient’s healthcare provider.

WHEREAS, as a result of step therapy, physicians are required to obtain prior authorization from the insurer before filling a prescription for some medications, and the insured must to get approval from their insurance company to confirm coverage under that plan. If prior authorization is required and approval is not obtained before filling the prescription, a patient could be responsible for all charges associated with the medication. In addition, healthcare providers are burdened to submit prior authorization requests to get insurer approval, while patients may have to wait multiple days to get access to the prescription.

WHEREAS, insurance companies practices of step therapy and prior authorization only serve to reduce drug spending and undermine physician’s medical criteria. Most of the reviews to provide drug benefit for a patient, based on meeting specific criteria, are administered by the insurers’ partners known as Pharmacy Benefit Managers (PBMs) which are independent companies overseeing the drug benefit programs. The most common PBMs are Medco, Caremark and Express Script. These practices negatively impact patient outcomes through improper treatment and fail to adequately assess the proper medications, which may put patients suffering chronic diseases ---and in need of specific prescribed medications--- at risk.

WHEREAS, some states across the country are already taking action to limit step therapy and prior notification practices to ensure that patients have access to adequate medications and to streamline the administrative process for physicians when prescribing medications needed by patients. WHEREAS, the most appropriate medical treatment and prescription drug should be determined within the healthcare provider/patient relationship. Only healthcare professionals familiar with a patient’s personal medical
history, including drug utilization, are aware of sensitivities and prior complications when determining the best treatment; and

WHEREAS, several advocacy groups including, but not limited to, the Lupus and Allied Diseases Association, Inc., the U.S. Pain Foundation, and the Coalition of State Rheumatology have advocated against these practices and push for legislative proposals to improve patient care and access to medication coverage.

THEREFORE BE IT RESOLVED, that the NHCSL supports policies that will provide alternatives to ensure that patients have access to their lifesaving medications; that encourage patients to engage in activities to educate respective communities on the Patient’s Bill of Rights; that help patients understand their insurance benefits and policies and empower them to make, with the advice of their physicians, the best decisions regarding their health, their treatment and their prescriptions; and

BE IT FURTHER RESOLVED, that the NHCSL encourages collaboration with health care companies and insurers that are truly committed to improve public health, ensure positive health outcomes for patients and promote transparency and guidelines to better understand their drug coverage policies.Be It Further Resolved, that a copy of this resolution be transmitted to the President of the United States,the Vice President of the United States, members of the United States House of Representatives, the United States Senate, and other federal and state government officials.


Sponsored by: Representative Louis Ruiz (KS)