Raleigh, N.C. — A new state House committee on Monday began considering whether North Carolina should regulate how insurance companies restrict the use of expensive drugs to save money.
Step therapy, also known as fail first, requires that patients start with cheaper drugs, even if their doctors prescribe something else. The insurance company won't approve more expensive drugs until cheaper ones have been proven not to work.
Insurers say the practice keeps drug prices under control, but patients with severe chronic illnesses say it causes health problems by delaying needed treatment.
Twelve-year-old Logan Govan has polyarticular juvenile idiopathic arthritis and waited a painful three years while his condition spread to different joints to get approval for the drug he needed. Meanwhile, the drugs he was required to try first had dangerous side-effects, said his mother, Mindy Govan.
"Why am I having to keep my son on this very potentially risky medication just to get to the right one?" Misty Govan asked lawmakers.
Michele McArthur, who has rheumatoid arthritis, is still waiting for insurance approval for the drug her doctor wants her to take.
"I'm on my fourth drug trying to get to the original treatment he wanted to give me two-and-a-half years ago," McArthur said.
Doris Ann Price, who pushed lawmakers earlier to limit the use of step therapy in North Carolina, had to send a letter to the House Select Committee on Step Therapy because she had to move to Boston in recent months to participate in a drug trial that she said she needed because here insurance company denied the treatments her oncologists sought for her metastatic breast cancer.
"Please stand alongside me today in the fight for my life," Price wrote in the letter, which was read by Donna Kaufman of the National Patient Advocate Foundation.
State Rep. Greg Murphy, R-Pitt, said he sees the problem of step therapy every day as a surgeon – and as a parent.
"My son developed epilepsy at age 14, and we went through five drugs in seven months of him seizing before we'd use the drug that we should have used originally," Murphy told his colleagues.
Murphy criticized the insurance industry's use of a panel of doctors and pharmacists to write formularies for cancer specialists.
"These fellows, this is what they do for a living, and having a family practitioner tell them which drug that they can use for oncology is, in my opinion, ludicrous," he said.
Insurers said they have processes in place for doctors to seek exceptions for certain patients, but the patients said those processes are not working.
Lu-Ann Perryman, a lobbyist for America's Health Insurance Plans, said changes could mean higher premiums for everyone.
"Limiting the ability of health plans to utilize step therapy only encourages the unsustainable increases in pharmaceutical costs and has a serious potential to harm patients," Perryman told lawmakers.
Step therapy works fine 90 percent of the time, said Ben Twilley of Express Scripts, who noted that his company only requires one step, not four or more.
"Ten percent is a decent number," Murphy said of the cases where step therapy doesn't work. "When it’s you, it’s 100 percent. So, there is work to do in that regard."
Rep. Pat McElraft, R-Carteret, echoed Murphy's concerns.
"I’m actually appalled at the other 10 percent and what they’re having to go through," McElraft said.
Gregg Thompson, state director of the National Federation of Independent Businesses, said employers need the ability to control drug costs as part of their health insurance plans, and step therapy is part of that strategy.
"The last thing they need is a new mandate to be passed that limits their ability to control costs," Thompson said.