It's a fairly simple concept: When ill, you seek an effective treatment.
Maryland lawmakers recently started the process with the hopes of ensuring a simple idea -- that doctors are the correct people to decide treatment for their patients -- becomes reality for patients.
During the last legislative session, however, health insurance companies opposed common-sense legislation introduced by Sen. Thomas "Mac" Middleton and Del. Eric Bromwell that would have brought about real change for Maryland doctors and patients by lessening the impact of a harmful cost containment practice known as "step therapy."
Step therapy effectively means a health insurance company or pharmacy benefit manager (PBM) can decide if they think a doctor's prescription is the "right" one for the patient. If the insurer or PBM thinks a patient can be treated with a less costly therapy, it will not cover or pay for what the doctor ordered and will instead insist the patient try the less costly therapy first.
If the patient fails to gain back health after that first "step," an insurer or PBM can mandate a second step or even a third step before agreeing to cover what the doctor initially prescribed for their patient. Not only is the practice of step therapy inefficient, it also takes the care of the patient and the responsibility for the health care of that patient out of the hands of educated and trained physicians. Health insurance companies and PBM bureaucrats should not be practicing medicine.
Health insurance companies put step therapy and similar practices in place with the intention of saving money. Doctors agree saving money in our over-burdened health care system is a worthy and righteous cause. Generally speaking, doctors will always prescribe a generic drug or seek out the less expensive treatment, but only if it will be effective enough to send their patient back to work or school and to achieve good health without unnecessary delay.
The Middleton/Bromwell legislation does not eliminate step therapy, but rather limits the length of step therapy to 30 days and allows doctors to override insurer step therapy when in the best interest of patients. The legislation has broad support from both doctors and patient groups. Unfortunately, the legislation failed to pass last year. Instead, the General Assembly decided to have the Maryland Health Care Commission study the legislation (SB 746/HB 1015) so they could complete work on the issue in the upcoming 2014 session.
The Maryland Health Care Commission is recommending what action the General Assembly should take next session. Maryland physicians and patients would like to see a ban or significant restriction on fail first or step therapy practices. MedChi, the Maryland State Medical Society, believes the Health Care Commission should support the legislation proposed last year.
This is an opportunity for Maryland lawmakers to help ensure their constituents' health care is provided by a doctor and not an insurance company or PBM, and that we, as patients, receive the most effective treatments based on our health and not a health insurance company's bottom line. We hope the interests of patients carry the day.
The writer is the CEO of MedChi, the Maryland State Medical Society. He can be reached via Twitter at @GeneRansom and email at firstname.lastname@example.org.