Maine Legislative Bill Challenges Step Therapy, Which Allows Insurers to Make Care Decisions

Many medical insurers follow a practice known as step therapy. A new law presented to legislators in Maine proposes to protect patients from such practices. In her column for Central Maine, Dr. H. Lori Schneiders offers her reasoning, and experiences in support of the new law. Keep reading to learn more, or follow the original story here.

Insurance companies are business. They use step therapy to test results against costs. The practice of step therapy involves a patient attempting treatment with a different drug than what has been prescribed. Sometimes insurance requires the patient to try many different drugs before they will approve of the doctor recommended option. Only when a treatment fails may the patient be covered for another. This is why people often refer to step therapy as “fail first.”

Dr. Schneiders lives in Cutler, Maine. She teaches at the University of Maine at Machias. Her fields of expertise include psychology and community studies.

Dr. Schneiders also knows a lot about rheumatoid arthritis. She’s had it for 40 years. She’s had autoimmune hepatitis for 11 years.

A steady regimen of medications keeps Dr. Schneiders diseases at bay. Without them, she says, she’d be “in a wheelchair within months, on a transplant list, or dead.”

So, the drugs Dr. Schneiders takes work. And yet, her insurance company forced her to try other ones instead.

Her condition proved stable. The drugs she takes had become neither unsafe nor scare. Still, her insurer insisted on other options. Both times, Dr. Schneider suffered anaphylactic shock and found herself in the ER.

Apparently her insurers are still not convinced. Despite her drug regimen working well for ten years, the company still insists on tweaking her treatment. Despite that each change poses a potentially lethal risk to Dr. Schneiders, they insists on changing dosages, and finding “proof” that she requires the drugs.

“The insurer, not my doctor, is in control of my treatment. That’s unacceptable — it’s dangerous for patients, and it’s anything but cost-effective.”

Dr. Schneiders continues by reminding her readers that she’s not the only one affected. About 70% of insurances plans require step therapy.

This is why, Dr. Schneiders says, she’s supporting L.D. 1407. The bill doesn’t expressly prohibit step therapy, but it does offer protection to patients. L.D. 1407 requires insurers to clearly explain their step therapy practices alongside their plans. The bill also demands that insurers provide clear and accessible means to appeal a step therapy decision.

Perhaps most importantly, the bill allows for health professionals to override the step therapy decision by an insurer when deemed medically necessary.

Dr. Schneiders believes she and her physician understand her body and her treatment far better than her insurance company does. The medication and treatment she and her doctor have agreed upon is crucial for her well being. In fact, it keeps her alive. Insisting that she continue to alter the proven regimen is, in her own words, unconscionable.

L.D. 1407, she says will keep patients safe. It will keep them out of hospitals, and emergency rooms. It lessens the burden on patients to make multiple trips, multiple payments, and on taking multiple risks. Furthermore, saving patients from emergency visits will save the Maine medical system significant costs. L.D. 1407 seems to make good sense. Dr. Schneiders believes it is, simply, “the right thing to do.”

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