By Shaina Smith
In a time when individuals are already concerned with the future of America’s healthcare system, one thing they should not have to fear is the ability to access medically necessary treatment options. Unfortunately, there are several states which currently do not protect patients from an insurance cost-saving protocol, known as step therapy. New Mexico has once again joined the list of states not shielding an already vulnerable population of residents from this potentially harmful insurer practice.
Known as the Constitution state, I am lucky to reside in Connecticut, where step therapy protections were made into law several years ago. As a person living with an incurable chronic pain condition, I do not have to worry when I visit the pharmacy to pick up a treatment, agreed upon between my primary care provider and me, that another medication (usually one that is less expensive than the originally prescribed medication) will be waiting for me to pick up. In other words, I am able to receive the medication that will best manage my conditions without interference from an insurance company.
In its simplest form, step therapy is a technique where an insurer will force a patient to fail on a series of medications before providing coverage for the originally prescribed medication. For those unaware, states where step therapy laws have not been put in place are seeing patients with cancer, HIV/AIDS, mental health, multiple sclerosis and other diseases forced to wait before they can begin effectively treatment and/or managing their condition. This, all so insurers can save money. However, when we look at the big picture of our healthcare system, step therapy can lead, not only to significant consequences for the patient, it can increase overall healthcare costs.
From the moment of diagnosis, all patients, including those within New Mexico should know that they will have access to the treatment option determined by their medical team to offer the greatest clinical benefit. Despite the incredible efforts of patient-driven organizations who came together in a grassroots fashion to champion House Bill 244 and Senate Bill 179, legislation that would curb step therapy practices, both bills died in Senate Finance.
From the patient perspective, I can personally relate to how devastating fellow pain patients in New Mexico must be; another year is going by without patient protections in place to offer a transparent process for overriding the unfair practice of step therapy. From an organization standpoint, U.S. Pain Foundation, which was part of the New Mexico Fail First Awareness Coalition, was disappointed that New Mexico could not join Connecticut and other states which has already passed step therapy/fail first legislation to protect its chronic pain patients.
Because chronic pain is a complex disease which requires a careful and balanced approach to manage, patients who are hoping to experience a better quality of life create a network of healthcare professionals that will support them during their pain journey. Pain patients carefully select the healthcare provider that best fits their health needs for various reasons and develops a trusting, respected and depended-upon relationship with their doctor. When, however, the treatment that has been agreed upon through the patient-doctor relationship is disrupted by protocol such as step therapy/fail first, it is the patient who is at risk for negative outcomes, while the insurer reaps the cost-savings.
It may prove difficult for advocates not to feel defeated after fighting on behalf of New Mexico patients who deserve basic patient rights and protections through HB 244/SB 179. However, we need to come together now more than ever to say to New Mexico lawmakers that we will keep coming back with legislation that allows all of its residents the opportunity to receive their medically necessary treatments timely and without disruption. While I cannot provide an answer as to why committee members did not push the bills through, I can offer hope and encouraging words to New Mexico pain patients who were depending on these bills to be turned into law. To those patients I say do not give up, because we are not giving up on you; we recognize the need for such patient protections and we will keep fighting for your rights as a person living with chronic pain.
Shaina Smith is a patient advocate and serves as Director of State Advocacy & Alliance Development for U.S. Pain Foundation. Through the organization, she has learned to live with pain and not in pain stemming from her condition, Ehlers-Danlos Syndrome.