At this year’s event, advocates let legislators and their staff know that in 2020 we want to see utilization management reform for insurers and review entities – specifically, new protocols for step therapy
and prior authorization.
Utilization management delays care and contributes to negative patient outcomes
Utilization management (UM) protocols are used by insurers to determine which medical services, treatments and prescription drug benefits will be approved for patients. UM protocols are becoming increasingly common across plans. Without proper guardrails, UM limits a health care provider’s ability to tailor care to your individual needs. For people living with psoriatic disease, prolonging or delaying treatment may result in increased disease activity, loss of function, and, possibly, disability.
One advocate, Shivani Chopra, has erythrodermic psoriasis and psoriatic arthritis. She recounts her battle with “fail first” step therapy protocols and why this issue is so important to her.
“I spent 10 years of my life disabled. I was told to fail first for 12 years of my life,” she says. Chopra is 36. “Not only did I have serious side effects from five years of chemotherapy, countless hospitalizations, surgery and epidurals in my spine, arm, legs and feet every two weeks, I lost my fertility. I have lost most of my bone density and now have osteoporosis with the bones of an 85-year-old woman.”
The importance of reforming step therapy or fail first is easy to understand, she says. “I do not want to see another soul suffer the way I did and still do today. We have a responsibility to help each other. I as well as these patients are not asking for a magic wand or a magic genie, we are simply asking for the tools to get better.”
Throughout the day, advocates told story after story about how they, or a loved one, had experienced barriers to care due to utilization management and explained why 2020 needs to be the year patients see change.
Expanding guardrails in 2020
In 2019, we have already seen four states (Georgia, Oklahoma, Virginia and Washington) pass similar legislation that addresses step therapy. There are now 20 states that have passed step therapy legislation. In California, patient advocates are looking to expand guardrails on legislation passed in 2015 with three focuses:
- Establish an exception process that ensures patients are getting the appropriate treatment for their disease.
- Expand current protections to Medi-Cal (a state program that offers free or low-cost health coverage for children and adults with limited income and resources). This legislation would include Medi-Cal in any new protections.
- Require that the utilization review organizations’ process for approval and denial be easily accessible, list criteria, and be based on clinical evidence, not cost alone.
Advocates wrapped up the day by meeting with more than 50 legislators and their staff, including meeting with every committee member from Senate and Assembly health care committees.
Many event participants are feeling energized and hopeful for 2020. “How many times in our lives do we get this kind of chance to help our community?” Shivani asks. “This legislation can be life-altering for many in our community, and I cannot wait to be there when it happens.”
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