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

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Esque

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.

Kathy C

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… Read more »

Tim Mason

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”

Rita Kimbel

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.

Maureen

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.

Diane Succio

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.

Bob Schubring

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.