After a late push by supporters at the end of the 132nd General Assembly, a proposal to set restrictions on health insurers’ step therapy protocols has reached the end of the legislative process.
The measure was folded into separate legislation that would allow insurers to reimburse pharmacists as providers (SB265, 132nd General Assembly), signed Friday by Gov. John Kasich.
The step therapy processes, also known as “fail-first” protocols, require patients to first try certain less-expensive treatments before moving to more costly options prescribed by their doctors.
The legislation: requires health insurers to provide a process for requesting exemptions from step therapy protocols, imposes deadlines for exemption requests and appeals to be granted or denied, and specifies circumstances in which an exemption must be granted. The requirements also apply to the Department of Medicaid.
“Patients and medical providers in Ohio thank Gov. Kasich for signing this bill and for protecting patients,” Dr. Christine Jaworsky, president of the Ohio Dermatological Association, said in a statement. “Setting reasonable safeguards on how step therapy is applied in Ohio has been the ultimate goal of more than 60 patient advocacy and medical groups in Ohio.”
The step therapy proposals started out much more controversial in separate legislation debated extensively in both chambers (HB72 & SB56, 132nd General Assembly). Medical groups said the protocols can hinder health maintenance by kicking people off treatments on which they’re stable and forcing people to try drugs they’ve had adverse reactions to before. Insurers and business groups, meanwhile, warned that allowing people to immediately go to more expensive treatments would drive up health care costs. (See Gongwer Ohio Report, April 11, 2018)
Entering the lame-duck session, the proposal’s sponsors vowed for a final push on the legislation, which had long been stalled. (See Gongwer Ohio Report, November 13, 2018)
Amendments made in the Senate Health, Human Services & Medicaid Committee removed some of the more contentious elements, including an exemption in cases in which a prescriber deems the exemption is in the best interest of the patient. With the changes, the Senate version passed that chamber unanimously. (See Gongwer Ohio Report, December 5, 2018)
“If a patient and doctor knows that one particular drug works better than all others, they should not be required to first try several others that may actually prolong discomfort and may or may not effectively treat the illness,” Sen. Nickie Antonio (D-Lakewood) said in a statement. “Healthcare decisions should be determined between a patient and their doctor – not insurance companies or other healthcare plans.”
Miranda Creviston Motter, president and CEO of the Ohio Association of Health Plans, said insurers wanted to make sure the broad exemption was removed from the legislation.
“OAHP supported legislative action that would protect patients from having to repeat step therapy for the same drug when they switched health plans,” she said in an email. “OAHP also supported the removal of the very broad ‘best interest of the patient’ exemption which would have undermined the step therapy process altogether and exposed Ohioans to higher drug costs.”
The original legislation, allowing pharmacists to be reimbursed as providers, was touted as a permissive move allowing for more team-based collaboration in health care.
“The signing of SB265 is a landmark victory for the profession of pharmacy,” Ohio Pharmacists Association President Ryan Schneider said in a statement. “This begins the next chapter in the evolution of the profession as pharmacists will now be recognized as providers of healthcare in the state of Ohio, which will allow for compensation for cognitive services.
“This brings us one step closer to more fully recognizing the value of pharmacists as an integral member of the healthcare team,” he added.
The OPA said recognizing pharmacists as providers will allow pharmacists to expand the ways they provide services.
“This groundbreaking legislation opens the door in both private and Medicaid programs for advanced pharmacy services to be reimbursed,” Executive Director Ernie Boyd said.