OP-ED: The Time’s Now for Washington State to Close Harmful Loophole

OP-ED: The Time’s Now for Washington State to Close Harmful Loophole

By Shaina Smith – U.S. Pain Foundation.

Among the 3,436 bills that have been filed so far in the state of Washington, there’s one in particular residents with chronic conditions will want to champion for this legislative session: House Bill 2310/Senate Bill 6147. Time will be of the essence, however, as Washington has an extremely short session—two months to be precise.

Why is this measure important for Washingtonians? For one, it provides prescription stability for families who rely on continuous therapies to manage chronic diseases such as arthritis, cancer, Crohn’s disease, chronic pain and epilepsy, to name a few. Many residents may not be aware, but insurers can make prescription coverage changes to its formulary after an individual or family has enrolled in a health plan. It’s disgraceful and shocking, but unfortunately true. Here’s how it works: Families and individuals often spend months researching the best health plan that will cover their medical needs. They select the plan during open enrollment and enter into a contract with that insurance plan. The enrollee holds up their end of the agreement—making monthly payments and staying in-network for the plan’s preferred list of doctors. The insurer, on the other hand, has the liberty to make midyear formulary changes, increase out-of-pocket costs and even move medications to a more restrictive tier. This insurer cost-saving measure forces adults and children alike off their medically necessary treatment option. The patient is then powerlessly driven to an alternative medication. This harmful practice, known as non-medical switching, is the loophole that currently exists in Washington.

Shaina Smith

Luckily for residents of the state, legislators have recognized the need to better protect the families they serve by introducing HB 2310/SB 6147. Advocacy action on the legislation, Concerning prescription drug insurance continuity of care, is off to an impressive start. Just recently, the Senate version was heard before the Health and Long Term Care Committee, where support outnumbered the opposition, 40 to 8. But it’s too early to get excited due to the predictable sentiments that are once again being shared by insurers, who claim that the appeals process is sufficient for ensuring continuity of care. Fortunately, Senator Rivers stood up to those arguments by saying the appeals process is not enough—I agree.

What’s more concerning than the opposition’s claim is that House Committee members are considering amending HB 2310 to limit it to the individual market, which, according to intel on-the-ground, is only about 4% of the population. All residents, not just the 4%, deserve protections to remain stable on their pharmacologic therapies. Such safeties can also benefit the economic and societal impact caused by non-medical switching.

If committee members are seeking to drive healthcare costs down, they should seriously consider voting in favor of these measures without amendments. Healthcare costs actually go up due to unprotected families taking extra trips to their doctor or the ER, undergoing lab tests or seeking outpatient care when their bodies negatively react to the change in their treatment plan. Those individuals with epilepsy, for example, who recently switched medications sought more in-patient and emergency care than those who did not.[1] Patients with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or Crohn’s disease who switch treatment due to a formulary change incur 37 percent higher all-cause medical costs (which include hospitalizations, ER visits, and outpatient visits) and 26 percent higher total costs than patients who are not switched.[2]

Medical continuity of care is not just a notion. It’s an individual’s livelihood and a right. House Bill 2310 and Senate Bill 6147 holds insurers and pharmacy benefit managers accountable so that once a family enters into a health plan contract, they’re not left guessing if their prescriptions will be covered or not. It’s time to protect families, including children and adults living with chronic conditions, from having appropriate treatment options financially inaccessible. All families deserve continuity of care, so let’s see to it that your Washington state Representatives and Senators vote in favor of these measures.

Shaina Smith is Director of State Advocacy & Alliance Development for the U.S. Pain Foundation

[1] Zachry III WM, Doan QD, Clewell JD, Smith BJ. Case-control analysis of ambulance, emergency room, or inpatient hospital events for epilepsy and antiepileptic drug formulation changes. Epilepsia. 2009:50(3);493-500.

[2] Chao, J., Lin, J., Liu, Y., & Skup, M. (2015). Impact of non-medical switching on Healthcare costs: a claims database analysis. Value in Health, Volume 18 (Issue 3), pp. A252.

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Authored by: Shaina Smith

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17 Comments on "OP-ED: The Time’s Now for Washington State to Close Harmful Loophole"

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I am really confused as a Washington state resident
I went to a town hall meeting of 43rd district couple Saturdays ago with my 18 year old
My representative 43rd district who was on the opiate committee said just that week it was decided no limits on opiate med pills if prescribed by an educated doctor I was surprised since I heard UW pain clinic ( clinic I go to is at capacity) said no referred overflow patients despite what they r on would not prescribe opiates I wanted be sure I heard correctly and after meeting my daughter and I spoke directly to her and I asked specifically about limits
Or MME. And could federal guidelines override and I was told no limits and between doctor and patient; federal guidelines I felt relief she said doctors and chronic pain patients had lobbied to state government. I sent an email thanking asked for bill # and never heard back. I was told my doctors will hear since just passed I saw my pain doctor who said I was mislead and with this article know a specific bill may have passed thru committee but not a law
Very disappointed in this misleading me.

We have a group of pain patients who have been attending the WA DOH Opioid Prescribing Committee meetings, where they are writing new restrictions. There is another meeting in March. Please join the Washington Pain Advocacy Group on FB. The C-50 (Coalition of 50 State Pain Advocacy Groups) has a group for every state. Look for your state name and ‘Pain Advocacy Group – we will not be heard until we speak as one.

A year long contract should be held for all including companies offering insurance. How do they break a contract and substitute with impunity?

Deborah, I couldn’t have said it any better. For me it started in June 2012 ….to this day after 11 back surgeries, many injections and just had the stimulator implant. The few percent of chronic pain sufferers are screwed, because these people that sit on their brains making big boy and girls decisions, thinks opiates don’t help with chronic pain and everyone that uses these drugs are for uforia reasons only. To me…instead of bunching chronic pain sufferers altogether …do it by a case by case basis. I’m not someone that was re-ended by a car going 5 miles an hour now claiming sore lower back or whiplash. I had the stimulator implant surgery because I have hopes of getting off meds….

Why oh why does the US have to have for-profit health care? Does anyone else see this as a conflict of interest and immoral at that? How can Big Pharma, Big Insurance and Big Corporate Hospital Groups continue to justify 20%+ yearly profits while patients struggle to maintain insurance, buy medications and afford doctor and hospital care? The American people are being squeezed to death as every penny is wrung out of them. The premiums, deductibles, co-pays go up every year. Even Medicare costs more. Our $1 increase in Social Security for this year is certainly not enough to cover these rising costs! The stress is enough to make one sick. We work our whole lives, paying into Social Security, so have we now become disposable? In a for-profit system are we seen as a drag on earnings?

This is great but what about people sick and disabled and do t have a spouse to provide good insurance
Also what good is paying for meds if the state andh federal governments put limits on amount opiates allowed
Unlike nsaids and Tylenol there is no ceiling and addiction and physical tolerance is not same
Addiction is an emotional need for meds and pseudo addiction
can happen when patients are under treated so they call more
run out because they do not have enough I am disappointed
our family doctors or internists or specialists are not fighting
for us partly they feel
DEA watching and believe “experts” who are cherry picked doctors know more about addiction then treating chronic nonmalignant pain
The CDC even said more of of
Deaths are from overdoses are heroin laced with a deadly form of fentanyl or sufentanyl
their patients and it is I believe
partly they think the people saying we don’t need doses
Above a certain dose unindividualized are not hearing the truth they do work
Often myself included go years
without change No one would want live like this my illness cost me a beautiful life not even counting the pain issue

Yep. Sure seems to be!

This is necessary more than you can imagine. The insurance companies don’t make the appeal process easy. Just reading the instructions to make an appeal is daunting enough, the doctor needs to get involved in the appeal process, which they don’t have time for and than the insurance company denies the appeal and you wind up in their game of appeals. Been there, done that!

I was hit by a Drunk Driver, my 15 yr old son pulled me through the windshield thinking I was dead. I spent years trying to find something to give me some quality of life. PT, Selfhypnosis, acupuncture, I lost count of meds I tried that had side effects worse than my injuries. I am not a drug addict, I do not abuse, sell or give anyone else my meds. I keep all my medication through 1 Doctor. I am 1 of many who follow all the rules and will be left with no quality of life, while those who abuse the system will continue to abuse it. SMH

is this policy the same with Medicare?

I am 57 and in chronic daily pain. Without the pain meds to take the edge off I would
have shot myself years ago. I have had many traumatic head injuries starting
when I was just 6 yrs old. I spent my entire life being tortured by doctors
with no reliefe. The only thing that helps is daily extended release Oxymorphone,
Klonopin, Imitrex, and Promethazine.

I got so tired of pain and doctors looking at me as a drug seeker I registered
as an Ohio DNRCC, do not resuscitate.

Insurers count on the fact that pts are not aware of their ability to appeal the “no decision” by the insurer and that the prescriber does not have – nor can afford – the staffing to appeal/contest every “NO” from the insurance company. The insurer is not obligated to tell the pt about their appeal process – UNLESS THEY ASK – then they are obligated to provide the detail/procedures of how their appeal process works. The insurer estimates at AT LEAST 50% of the “NO’S” that they do.. the pt will just cave and go away.. the most profitable thing for the insurer to do is to is “JUST SAY NO”.. They also hope that the prescriber will just cave and agree to the “cheaper therapy” that they are willing to pay for.. because the insurer is a FOR PROFIT BUSINESS and their financial health is more important to them that the quality of life of the pt. The insuer’s appeal process is most likely a multi level process and until we get to a point that EVERY PT appeals EVERY DENIAL…it will be business as usual for the insurer.. only once the insurer gets overwhelmed with appeals.. will they give second thoughts to making changes mid-year… because they will be the one that doesn’t have the staffing to handle all of the appeals nor will they want to pay for all the cost involved with the “outside independent reviews” that they will have to pay for if the pt follows thru all the steps of the appeal process that they are entitled to.

This is short sighted.

Pharmaceutical intervention will often keep expensive ER visits down. A good maintenance medicine routine can stretch the time between visits. Money saved for the health plan

I had a doctor refuse to prescribe catapres. A doctor. Catapres is taken when your blood pressure gets to stroke level. A pill that almost instantly lowers BP to ok levels prevents an ER visit to lower it and keep the accompanying migraine type headache at bay. (not the insurance company here but the doctor) I have NO CLUE what her motives were..

Where is all the madness coming from? It is not just pain pills.

My plan switched a prescription tier on me last year! A medication that has been generic for over a decade is now a tier 3 drug!!! What used to cost me $15 is now $227.
Didn’t know it until I filled it through my mail order program. I’m sure they will find yet another one to upcharge this year. (FYI- they pass the buck by blaming the manufacturer.)
Shameful! I’m sure that’s why they ask you about your medications when you look at plans for the following year. Not supposed to discriminate against those of us with pre-existing conditions, yet they get around it. I was a health insurance agent for over 15 years and I thought I knew all the games they played. They stack the deck in their favor and guarantee their CEO’s hundreds of millions of dollars in annual bonuses and compensation. And they are the biggest drug pushers around. $5 BILLION dollars annually goes to advertising their drugs to CONSUMERS, when they should be honestly telling the doctors and the pharmacists the real truth about these drugs. Once again, absolutely SHAMEFUL!

Could you please tell me how I could get results for the State of Mississippi?

This is a dire necessity for every citizen in every state! Health insurance companies hold all the cards and can change terms and conditions of the contract whenever they choose. Their CEO salaries and bonuses are tens of millions each year. The American people with chronic illnesses have been thrown to the curb by our political system due to the “opioid epidemic.” They can’t get proper medical care anymore since their doctors risk losing their license and pharmacists won’t fill the prescriptions anyway. This is a rerun of the McCarthy era. Let’s pray this passes and other states follow quickly.