Legislature Passes Bill to Limit the Use of Step Therapy

(BOSTON – 10/24/2022) The Massachusetts State Senate on Monday enacted legislation to limit the use of step therapy, or ‘fail first’ protocols that too often direct patients to cheaper medications rather than those more suitable to treat their condition. The bill, An Act relative to step therapy and patient safety, gives health care providers more leverage in determining the most effective treatment options for patients, saving patients expensive and painful regimens on medications they know to be ineffective or harmful. This bill builds on similar legislation passed by the Senate in 2020.

“Insurance companies have long used the ‘step therapy protocol’ to allow them to delay or forego paying for medical treatments that patients need,” Senator Michael Moore (D-Millbury) said. “This bill will save lives and prevent suffering by allowing doctors and patients more leverage to choose the medication or treatment that gives them the greatest chance of recovering, without being forced to first undergo cheaper treatment that their doctor believes will be ineffective. Healthcare decisions should be in the hands of patients and their doctors – not insurance companies.”

Step therapy serves as a cost-saving mechanism that can limit a patient’s ability to access the medication that is most suitable for treating their condition. Insurers that utilize step therapy protocols require medical providers to prescribe lower-cost medications to patients first, and only grant approval for alternative medications when the cheaper options have failed to improve a patient's condition. In practice, this results in insurers effectively choosing medications for the patient, even in cases where their providers have recommended an alternative. When patients change insurers, they are often forced to start at the beginning of the step therapy protocol again, which results in wasteful health care expenditures, lost time for patients, and potentially devastating health care impacts on the patient.

Step therapy is not limited to specific diseases. It affects patients across the healthcare spectrum, with particularly dramatic impacts on the allergy and asthma, antipsychotic, arthritis, cancer, coronary artery, depression, diabetes, HIV/AIDS, multiple sclerosis, and Parkinson’s patient communities.

To address this, the bill establishes guardrails to protect patients in circumstances in which following step therapy protocols are counterproductive or harmful. The bill prohibits insurance providers from establishing a step therapy protocol that requires an insured individual to utilize a medication that is not likely to be clinically effective for the prescribed purpose. When establishing clinical criteria for step therapy protocols, the bill would ensure that insurance providers determine effectiveness through clinical review and take into account the needs of typical patient populations with similar diagnoses.

The bill provides patients who are subjected to step therapy sequences with an accessible exemption request process whenever coverage is restricted. The legislation enumerates specific timelines for insurers to review requests and grant exceptions, and in cases where interruptions in the patient's medication schedule puts them at considerable risk, the turnaround time is faster. Under the bill, providers would accept or deny a request within 3 business days or within 24 hours if additional delay would significantly risk the insured individual’s health or well-being. If an exception to step therapy is denied, the bill includes a process for the decision to be appealed.  Upon granting exemptions, MassHealth and private insurers would be required to provide coverage for the drug recommended by the patient's provider.  

To assist in future reforms, the bill would create a commission on step therapy protocols within MassHealth to study and assess the implementation of this bill and any future step therapy reforms.

If passed, Massachusetts would join 28 other states in curbing unfair step therapy practices. The bill, An Act relative to step therapy and patient safety, is now before the Governor for his consideration.

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Letter to DPU: Winter Energy Rate Increases

Dear Chair Nelson:

We write to convey our deep concerns related to the proposed energy rate increases for this winter season as multiple investor-owned utilities seek to saddle drastic cost increases on our constituents. As the Department of Public Utilities (DPU) is the oversight entity for investor-owned utilities in the Commonwealth, we implore you to protect Massachusetts residents from these rate increases.

As the basis for increasing rates, these utilities have cited Russia’s invasion of Ukraine, inflation, and other factors; however, our constituents already feel the impacts of these macro-economic factors. They encounter them when they buy groceries, fill up their car, or pay for medical expenses. Under the proposed rates, keeping themselves warm during the winter would be just another heightened cost passed along to Massachusetts residents.

It is also important to highlight the fact that this rate increase is being proposed on top of significant energy cost increases already imposed on Massachusetts residents within the last year. As noted by DPU:

The Department is very concerned with the energy burden on customers and the increased costs of all energy sources. Gasoline, propane, oil, natural gas, and electricity costs have all significantly increased over the last year. The Department agrees, however, that the increase in electric supply costs is particularly concerning. While natural gas customers are expected to experience about a 20 percent bill increase due to rising natural gas supply costs, the electric supply costs through National Grid’s Basic Service are expected to increase an average residential customer’s electric bill by over 80 percent from current rates.

According to estimates by the Department of Energy Resources, this winter will be colder than last year while the “cost of heating for residential customers is expected to be 28.6% higher for homes heating with natural gas, 18.6% higher for heating oil, 3.0% for propane, and 54.6% for electric heating.”

We echo the Attorney General’s concerns with these proposed rate increases. In addition, proposed rate increases of this magnitude – during the winter season – would disproportionally impact the Commonwealth’s most vulnerable. Moreover, protecting our residents from the cold is not just an affordability and equity concern – it is also a public safety issue. As the oversight agency tasked with prioritizing safety, affordability, and equity with regard to energy rates, we ask that DPU do just that and protect Massachusetts residents from these drastic rate increases this winter season.

Please do not hesitate to reach out if you have any questions. Thank you for your attention to this matter.

Sincerely,

Senators Michael O. Moore, John C. Velis, Diana DiZoglio, Joanne M. Comerford, Ryan Fattman, Patrick O’Connor, Jason M. Lewis, Adam Gomez, Anne M. Gobi, Edward J. Kennedy, Barry R. Finegold, Susan L. Moran, Walter F. Timilty, Sonia Chang-Díaz, James B. Eldridge, Eric P. Lesser, John F. Keenan, Lydia Edwards, Michael D. Brady, John J. Cronin, Patricia D. Jehlen, Marc R. Pacheco, Joan B. Lovely, Becca Rausch, Julian Cyr, Mark C. Montigny, Paul R. Feeney, Bruce E. Tarr, Harriette L. Chandler, Sal N. DiDomenico, and Brendan P. Crighton.

Representatives Orlando Ramos, Andy X. Vargas, Michael J. Soter, John Barrett, Timothy R. Whelan, Brian W. Murray, Paul J. Donato, William M. Straus, Steven Ultrino, Susannah Whipps, Jamie Zahlaway Belsito, Christine P. Barber, Michelle Ciccolo, Todd M. Smola, Natalie M. Blais, Michael P. Kushmerek, Danillo A. Sena, Patrick Kearney, Paul Mark, David Allen Robertson, Mindy Domb, Carole Fiola, Josh S. Cutler, Smitty Pignatelli, Peter Capano, Hannah Kane, Carol A. Doherty, Patricia A. Haddad, Joseph McGonagle, Steven G. Xiarhos, Mathew Muratore, Carlos González, Shawn Dooley, Mike Connolly, Kimberly N. Ferguson, Lindsay N. Sabadosa, Tram T. Nguyen, Jacob R. Oliveira, Kay Khan, Brandy Fluker Oakley, Jonathan Zlotnik, James J. O’Day, Gerard J. Cassidy, Steven C. Owens, David K. Muradian, Jr., Natalie Higgins, Bradley H. Jones, Jr., Susan Williams Gifford, Jay D. Livingstone, Thomas M. Stanley, Paul K. Frost, Frank A. Moran, Meghan K. Kilcoyne, Mary S. Keefe, Jay Barrows, David LeBoeuf, Alan Silvia, Joseph McKenna, Ken Gordon, Christopher M. Markey, Linda Dean Campbell, Liz Miranda, Kevin G. Honan, Danielle W. Gregoire, Marc Lombardo, Ruth B. Balser, Kip A. Diggs, Jeffrey R. Turco, Carmine L. Gentile, Elizabeth A. Malia, Steven S. Howitt, John J. Mahoney, Tami L. Gouveia, Daniel M. Donahue, Colleen M. Garry, and Joseph F. Wagner.