Many Texans are wringing their hands as they start their new "plan year" and seek to understand what their health plan may cover and what it may not. For patients with hard-to-manage chronic conditions, uncertainty around their health insurance coverage and barriers to prescribed treatments are an all-too-common reality they must face each year and every day.
Last spring, the
You may not know the term "non-medical switching," but you or a family member may have experienced it. It's a common insurance industry cost-cutting strategy, similar to step therapy or "fail first" mandates, where health plans push stable patients to a drug other than the one prescribed by their physician. The change is based on savings for the insurer or pharmacy benefit manager, not the patient's health, symptoms or personal preferences.
Losing access to an effective medication can be devastating for patients whose conditions have been stabilized by their physician-prescribed drug. People with chronic illnesses like arthritis or diabetes often take multiple medications every day, allowing them to lead normal lives and avoid other, more costly forms of care such as hospitalization or extensive testing.
One study clearly demonstrated the negative effects of non-medical switching. It found that nearly 60% of switched patients reported a complication from the new medicine, such as a new side effect, re-emerging symptom or interaction with another medicine they took. Patients also reported being less able to care for family members or to remain productive at work after the switch.
We all want wise health care spending. But Texans can agree that cutting costs by interfering with the patient-physician relationship and overriding medical professionals' expertise is not the way to do it. Prescriptions written by highly trained physicians should not be treated like casual suggestions for health plans to follow or disregard as they see fit. After all, gaining access to effective treatments is why people buy health insurance in the first place.
My bill, HB 2099, would have codified these values. It sought to protect Texans' health and the sanctity of the patient-physician relationship by prohibiting health plans from switching a patient off of a medication that was keeping him or her stable. The bill still allowed for the practice of generic substitution to reduce costs, and insurers still would have been able to adjust their formularies, just not in a way that would deprive stabilized patients from necessary, long-term medications prescribed by their doctors.
With the help of my fellow legislators, I hope that a year from now, we will succeed in getting a patient-focused bill onto
Lambert represents the
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