MA Senate Aims To Reduce Drug Spending With Step Therapy Reform

August 03, 2020 - The Massachusetts State Senate has passed a bill that would introduce step therapy reform, restricting a practice that payers commonly use to decrease patient prescription drug spending.

“Patients with complicated illnesses should be receiving the medications that their doctors know they need—not repeatedly taking medications that they know to be ineffective just to help insurers save on costs,” said State Senator Julian Cyr (D-Truro), chair of the Joint Committee on Mental Health, Substance Abuse, and Recovery.

Senator Cyr was a sponsor for the legislation. He argued that, while step therapy reduces costs at the front end, it results in a higher bill for patients later in their care journey when their condition further devolves and requires higher cost treatments.

Step therapy implements prior authorizations that require patients to start at the lowest cost version of a treatment, usually a generic, before graduating to more expensive and potentially more effective versions of the drug. Patients can only graduate to the next “step” when their current step proves ineffective against their condition.

One of the challenges with this system is that when a patient switches to a new payer, they may have to start the step process over again. Not only can this result in higher healthcare spending but the setback can negatively impact patient outcomes.

The legislation does not entirely eliminate step therapy but rather it aims to give providers more power to determine when step therapy would produce negative patient outcomes. It also allows providers to request an exception from the step therapy requirements in those cases.

Payers would be required to report to the state’s Division of Insurance details regarding top therapy exception requests that they denied. The Division of Insurance would also be in charge of providing oversight for step therapy programs.

“This bill takes an important step toward placing treatment decisions back in the hands of the health care provider and patient by limiting opportunities for insurance companies to force a patient to fail on certain medications before they can access the one most suitable for their needs,” said Senator Cindy F. Friedman (D-Arlington).

Senator Friedman is the co-chair of the Joint Committee on Health Care Financing and she played a key role in raising this legislation.

“While we must continue to address the high cost of drugs, we cannot do it at the expense of patients, and cost can never be the primary determinant of whether a patient has to suffer needlessly before they can access the medication that is most effective for treating their condition,” Friedman continued.

Patient advocacy groups and provider organizations have banded together in the past to protest step therapy practices.

Let My Doctors Decide, a patient advocacy group, suggested Patient Principles, a set of guidelines to enforce a more patient-centered, personalized process for patients in accessing treatment.

Other states have already moved in the direction that Massachusetts is considering. Minnesota passed a law in 2018 that allowed patients and providers to override payer step therapy requirements. Minnesota was the 19th state to pass this reform. If the bill passes in the House, Massachusetts would be the 29th state to approve step therapy reform.

In contrast with the Massachusetts State Senate and other industry stakeholders, CMS has employed step therapy as one of several strategies to bring down prescription drug spending.

In 2018, the agency established a rule that permitted Medicare Advantage plans to set up step therapy for new enrollee prescriptions. CMS recommended strong beneficiary engagement and enlisting the help of pharmaceutical and therapeutics experts to decide for which scenarios step therapy would be most effective for cost and outcomes.

Now that the Massachusetts step therapy bill has passed in the state’s Senate, it will move on to the state’s House of Representatives.