Reluctance from New Mexico Lawmakers to Pass Step Therapy (Fail First) Bill Once Again Poses Health Implications for Chronic Pain Patients

Reluctance from New Mexico Lawmakers to Pass Step Therapy (Fail First) Bill Once Again Poses Health Implications for Chronic Pain Patients

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.

Shaina Smith

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.

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Authored by: Shaina Smith

There are 7 comments for this article
  1. Esque at 11:25 am

    As a New .exuco Pain Patient, I suffered greatly when Christus St.Vincent closed down the excellent Pain Dr clinic of Belyn Swartz citing money problems. That was a lie. There is no way to get opiates from the largest prOvider in the state. They said see your primary doctor- all b primaries refused to write for opiates as well. Found one who wrote 1/3 of what I’d had before. Turned to the black market in another state, once was sold fakes w fentanyl- horrible $$$-costing thousands, lost most of my savings until FINALLY finding an addiction specialist!!not a physiologist/pain doctor like Dr Schwartz that after seeing my records, agreed to write . Although I had drug tests before, now, every time plus pill counts that are 1 hour of driving away. Still plenty of heroin addicts. Even when they can’t get, they want it. Suboxone should be EASY to get- instead I hear you have to go to counseling every week and do drug tests at all sorts of things and so of course people that are heroin addicts find those structures and the costs unbearable. Addicts AND pain patients have it bad here. However, it seems to be a problem everywhere, Colorado for sure having many untreated pain patients esp on the Western Slope. So many unproductive painful lives wasted.

  2. Kathy C at 12:29 pm

    Thank You Shaina,
    I live in New Mexico and have been following that bill. It is well meaning, but here in the “Land of Enchantment” Pain Patients have effectively been silenced. I have been following “Local” News, which never mentioned this Bill, Out here we have little Independent Journalism, and this state has had a long problem with Opiate Addiction. Northern NM has had virtual monopoly on Healthcare Provided by a Religious Non Profit. Since the area already had a Heroin Problem, many switched to pills when they were available. The usual narrative about “Addiction” is already in place. Even with the long history of Drug Addiction, New Mexico has done little to address Treatment. There are virtually no “Pain Physicians’ and the so called “Addiction’ Specialist still do not have an evidence based way to distinguish Pain Patients and Addicts. This State decide to label any Opiate usage as Addiction.
    Since the area already had a problem many Pain Patients were already being scrutinized. The Religious Non Profit, a large HMO, with most Physicians in some way already using their “Guidelines.” They appear to be denial of pain. Their Physicians are not allowed to even acknowledge that pain exists. We are in a strange alternate Universe out here. most of the Articles that appear in “Local News” don’t even mention pain as they re-iterate tragic and anecdotal tales of death and addiction.
    The Step Therapy Bill, appears to be a step in the right direction, but due to the Hysteria here it is unlikely it will affect anything much. There really is no way to get any Physicians to comply. their HMOS and the Insurance Companies already have free reign. There is also a very uninformed public. Hardly a week goes by when there is another riveting story of death and addiction, with no counter by mentioning “Pain Patients or Chronic Pain.”
    Even introducing this Bill gives the misleading impression that Insurance Companies follow any Rules. We are in the Post Era out here. The word “Pain”has been struck from the Lexicon. Physicians are more susceptible to Pharma Hype and Advertising than Facts. The only “News” people get around here is following a strange narrative. We have Department of Health Public Relations people writing content for Advertising Supplements. They do this without even identifying themselves. Each Article misrepresents the “Crisis,” with an Anecdotal Story of an “Addict” in this case a young man injured in an accident. He took too many Pills, became addicted and turned to heroin.
    The State Epidemiologist is quoted, claiming this State is “Recognized as a leader in Policy Interventions and Innovations.” New Mexico has had a problem since 1992 and even earlier, with generational Opiate Abuse. There is no way to interpret these kinds of Statements, they are fluff and hyperbole. The Local Media is not telling the whole truth, because from casual observation, this State still has a drug problem. Driving down the street, shows a number of Homeless, Panhandlers, and people with vacant stares. The Local religious non Profit Hospital, just closed another “Facility.”
    The current “funding Crisis” made it clear that they might not get the “Reimbursement” they feel entitled to. The largest best funded Religious Non Profit shut down a Treatment facility, and not one local “journalist” even asked any Questions. The CEO released some well spun statement, but what really happened is that they ran the numbers. Newspapers, Billboards and TV News, keep sensationalizing the “Drug and Substance Abuse Epidemic. At the same time they are closing treatment faculties. They are also running a false narrative from the Right Wing about Charities and Religious groups being an alternative to Government funding. Nearly every Article mentions an Anecdotal Story of a person that got help at a well meaning “Non Profit.” They take these success stories out of context, using one example no mention of the many that dropped out, the “cure’ rates are abysmal, but these kinds of facts are left out.
    This “Bill” is another Industry Trojan Horse. They make it appear to help a few people, but the ‘Facts” don’t apply out here. More than half of the Legislature uses their “Beliefs” not Facts to make Policy Decisions. State Agencies are not collecting relevant data, anything that might make a Provider unconformable. This “Step Therapy” is too complicated for most of them. The Insurance and Healthcare Providers have deep pockets, and their “Education” is very compelling.
    Pharma Advertising has penetrated every source of Information. The use of “Advertorials” in Local news is particularly intrusive. Even when these Politicians and Policy people rail against Big Pharma, they are at the same time promoting it. The Insurance Industry and Local Business have a financial Interest here. Denying care is now in the Patients best interest because the Specter of Addiction is so terrible. The Insurance Companies have a lot to gain. The blurring of the Definitions, and even the Billing, where most Government Agencies collect data, have all been skewed to reflect Industry Interests.
    Even some of the credible appearing Medical Information is written to deliberately mislead. The Titles and Summaries reflect Biased information, while the same Article contains a Disclaimer that negates the Title, usually catchy bias affirming, Pharma endorsing click bait. This is the kind of Article they write to deceive and promote a Pharma Product.. https://www.sciencedaily.com/releases/2014/08/140829175430.htm Antidepressants show potential for postoperative pain (Based on 15 Trials) They mention the Agency for Healthcare Quality to endorse the Statement.
    “After searching through three databases of trials, first author of the paper and fifth year anesthesiology resident Karen Wong sifted through 1,350 records from three different research databases to select the 15 trials for detailed review.” (The Cherry Picking is evident here)

    “Just over half of the trials examined showed a reduction in pain after use of antidepressants.” (Cherry Picking again, no mention of the other 50% meaning those outcome were likely negative or inconclusive. Awfully vague evidence that any of these are effective, at the same time, a Profitable assertion for Big Pharma. There is virtually no Clinical Evidence to support the use of Anti Depressants. Physicians are not allowed to rely on their own observations. The Trials are probably funded by Big Pharma, and not compared with opiates or other Pian relievers., just a barely observable effect, on reported pain, that could even be attributed to the Placebo effect. Every Article contains a disclaimer, in case the Author or Researcher is ever questioned, or the Science gets checked. That seems very unlikely anymore.
    (One more “Analysis” The “Summary” is completely negated by the findings. 9 Percent of participants pulled out, due to adverse effects. (The assumption that any of these drugs are effective is ridiculous, simply not proved here. Nine Percent “Dropped Out” and Adverse events could be the noxious Side effects or the Pain was unbearable and had to be controlled with Opiates. We also have no idea of the severity of pain they are dealing with. There is a big difference between the pain from Open Heart Surgery, and an Appendectomy.
    People we are now in the Post Fact and Post Science Era. These are the kinds of Articles that are referred to. The clearly evident bias, and the Title alone re-enforce the Pharma narrative, and give the appearance that all pain can be controlled with Anti Depressants. Physicians are targeted by the Pharma Industry with these misleading Articles. These Anti Depressants are more expensive too, and can be continued indefinably, the Withdrawal effects are not noted.
    Physicians that use this information to deny Post op pain care, won’t be noting the response. They are well instructed in Liability by their Employers, who will seize on this and use it on Patients that not assertive, or whose Insurance does nto reimburse enough. The “Liability” dogma is another misrepresentation. The Industry has been using the Possible Liability to influence data and Reporting Requirements. The Fact that less tan 4% of Their Costs might be attributes to “Liability” has been replaced with another “Tort Reform” explanation for the expense of our Healthcare System. HMO’s have High Powered Lawyers on their Payroll to guide their decisions, this Cost is Included in that 4%. These Lawyers do a lot more than Protect against Liability, they also focus on the profitability and what the Provider can get away with.
    There is a constant barrage of these deliberately misleading Articles. They tend to go Viral when they promote the Industry and reinforce the biases. The Articles that might question their methods won’t be mentioned. The damage is already done, the use of Facts to counter these Conclusions won’t be repeated in the Media, or General Medical “Information.” We all have to read between the lines, The “Step Therapy Bill” was one more way for Big Pharma and the Insurance industry to intrude in Medical Care and make sure that their Interests, the relentless Profit Driven System is well represented.

    https://www.ncbi.nlm.nih.gov/books/NBK126164/?report=classic
    Know Your Chances: Understanding Health Statistics.
    “Why is it so hard? First, there are problems with the messages: many are incomplete, misleading, or overstated. It’s easy to understand why. The message writers may not know what they’re doing—or, more likely, they may know exactly what they’re doing. Without doubt, the media, medical journals, pharmaceutical companies, researchers, research funders, and academic institutions all have an interest in being associated with work that is perceived to be big, new, and important. That is a recipe for exaggeration.”

  3. Tim Mason at 6:33 am

    Where I have seen “Step Therapy” implemented is when a person changes Pain Management doctors. It is usually posted on the wall of the exam room and states.
    Regardless of the medication you were taking, insurance requires us to start over with lower dose and possibly different medications when evaluating a new patient”
    Next to this is a sign that states. No taping or video recording during your exam without written consent from the provider”

  4. Rita Kimbel at 6:19 am

    Thank you for the information, presently I am in a battle with United Health care. They have taken away the oxycontin, want me to take xtampa but in the lowest dose available. I have neurogenic pain from a Spinalcord injury since 2003, I have a neurostimulator implant since 2006 to help curb the pain. I don’t have the resources to battle for my medication and have become a victim of the opioid epidemic problem. I wish I had Shaina in Pennsylvania to help me right now because I and my doctors are at our wits end since January this year. I have so many questions and need some guidance.

  5. Maureen at 5:46 pm

    Shaina, excellent and informative post. ‘Thank you’ for all that you do on behalf of US Pain foundation and for all of us pain Warriors.
    While I made the huge mistake of moving from CT. and a wonderful caring pain management Doctor 2yrs ago… to be closer to family in Florida for ‘support’ (where both doctor’s here and my family are are greatly non-supportive)…
    I forget that others are still dealing with the step-therapy issue.
    I will keep them in my hopes and prayers for positive changes real soon.

  6. Diane Succio at 1:44 pm

    I am taming a medication for migraines and have been on it for 8 years. I transferred within my company with the same insurance but in a different region. When I went to refill my meds, I was told they wouldn’t cover it as there we’re different meds that we’re cheaper and I had to try and fail 3 different kinds. My Doctor flipped out and after going back and forth with the Insurance Company, they finally paid for the original script. It was ridiculous what they wanted me to go through.

  7. Bob Schubring at 12:07 pm

    It’s important to write clearly, so that first-time readers grasp a concept immediately. Using the phrase, “insurance cost-saving protocol” in the the​ second sentence, was simply a bad choice of wording.

    Why?

    Because the writer then goes on to prove, that in the process of harming patients, the Protocol increases the costs that it was intended to reduce.

    That confuses readers.

    It would be better to call Step Therapy what it is:. A protocol devised by lobbyists for the addiction-treatment industry. Insurers find it useful to ally with that industry, right now, because that industry has the ear of a handful of prominent politician, and it asserts that vast sums of money will be saved, by flushing all “addicts” out of the healthcare system and forcing them into Addiction Therapy as a condition of remaining free and getting care.

    The imaginary cost savings are not backed by any observed set of facts. Therefore it is error to call the protocol one of cost-saving.