In Massachusetts, some patients with epilepsy must try and fail on their health plans’ preferred prescription medications not once, not twice, but three times before getting the treatment their doctor originally prescribed. Known as step therapy, the process is designed to reduce health plan spending by driving patients to the lowest-cost drugs. But in some cases it forces patients to suffer unnecessarily and, ironically, leads to higher overall costs due to extra physician visits and hospital care.
Perhaps that’s why Massachusetts legislators are pushing to limit the practice by MassHealth, the state’s Medicaid program.
Senate Bill 602 would streamline the process to just one step for epilepsy patients. Those who fail their health plan’s preferred epilepsy drug would move directly to the therapy prescribed by their physician, with no other failure required. The bill also creates an exemption process, allowing physicians to override the step requirement if it is medically inappropriate for a given patient. This protects patients who are particularly vulnerable or who may have already completed a fail first process with a prior health plan.
The bill follows the lead of several other states. California, Maryland, New York and Connecticut all limit epilepsy patients’ step therapy to just one failed medication attempt. Meanwhile, few states allow Medicaid to subject epilepsy patients to three steps.
And the measure could even help Massachusetts reduce unnecessary health care spending. Failing on an epilepsy treatment can result in breakthrough seizures, leading to emergency room visits and hospital care. Reducing such incidences could help lower the state’s 2015 ranking as 31st in the nation for avoidable hospital care costs, as reported by the Commonwealth Fund. That year, Massachusetts saw nearly 2.5 million emergency room visits.
Equally valuable, the policy shift would help put epilepsy patients and their physicians back in control of treatment decisions.
S. 602 is scheduled for a legislative hearing in July.