KHI News Service

Bill would require KanCare patients, doctors to first try lower-cost drugs

‘Step therapy’ proposal for Medicaid prescription savings draws concern from mental health advocates

By Meg Wingerter | January 27, 2016

Gayle Taylor-Ford’s husband has been waiting two months for the treatment his doctor thinks is most likely to help with his multiple sclerosis, a wait she attributes to their insurer’s step therapy protocol.

Through step therapy, doctors and patients must document that lower-cost drugs didn’t work before a more expensive prescription can be tried.

Photo by KHI News Service File Photo Budget Director Shawn Sullivan said Wednesday that allowing the three managed care organizations that administer KanCare to use step therapy for prescription drugs could save the state $10.6 million annually. Through step therapy, doctors and patients must document that lower-cost drugs didn’t work before a more expensive prescription can be tried.

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Taylor-Ford and others spoke Wednesday at a Senate Public Health and Welfare Committee hearing on Senate Bill 341, which would allow step therapy in the state’s privatized Medicaid program known as KanCare.

Budget Director Shawn Sullivan told the committee that allowing the three managed care organizations that administer KanCare to use step therapy could save the state $10.6 million annually, part of an effort to slow a steady increase in the $3 billion program’s pharmacy costs.

Taylor-Ford, of Overland Park, said a multiple sclerosis specialist told her it probably would take about two months to get her husband the drug the specialist thought would be most likely to work, because he expected their insurance company, United Healthcare, to deny prior authorization on the medication.

“Right now we’re just in a holding pattern,” she said.

They prescribed an infusion of steroids to reduce swelling on her husband’s brain, Taylor-Ford said, but the steroids raised his blood sugar and caused severe swelling. His mobility suffered to the point that doctors suggested placing him in a rehabilitation facility until the medications came through — a move they are reluctant to make because her husband is only 49.

“He cannot walk upright. He hobbles. He’s fallen so many times,” she said. “His ankles are swollen to the size of my thighs.”

Sen. Jim Denning, a Leawood Republican who works as a health care administrator, testified in support of the bill. Patients who already are taking a drug that is a “step up” from the less costly first-line treatment wouldn’t be required to start over, he said, adding the bill wasn’t intended to apply to drugs taken for mental health conditions.

Doctors’ offices could keep track of what drugs are on what step, Denning said, and go through the prior authorization process if they believe the first-line drug wouldn’t benefit their patients.

“It’s going to be extra work. It’s too bad the physicians can’t share in the savings,” he said.

Eric Voth, vice president of primary care at Stormont-Vail Healthcare in Topeka, said Denning’s description of the process was a “sugarcoating” of prior authorization, which sometimes takes an hour or more.

“We play this game on the phone of cat-and-mouse” with the insurance companies, he said. “You have insurance companies playing doctor.”

If the committee moves the bill forward, Voth said, it should add provisions that require insurance companies to share their reasons for making medication decisions and should exempt conditions like mental illnesses, diabetes and epilepsy.

Legislation last year placed mental health drug recommendations for KanCare in the hands of a committee but didn’t specifically address step therapy. Mental health advocates told legislators Wednesday they wanted stronger assurances that those drugs would continue to be exempt.

Susan Crain Lewis, from Mental Health America of the Heartland, said step therapy would result in fewer people with mental health issues complying with their medications.

“Step therapy has been shown to result in people never starting or starting and stopping medications,” she said. “Our providers and our patients already struggle to find the best medication with side effects the patients can live with.”

A review of 14 studies of step therapy published in the Journal of Managed Care Pharmacy in 2011 found reduced costs when step therapy was used for antidepressants, antihypertensives, nonsteroidal anti-inflammatory drugs and proton pump inhibitors. They didn’t find significant savings from requiring step therapy for antipsychotic drugs.

The study found using step therapy with NSAIDs and PPIs – which are used to treat pain and acid reflux, respectively – decreased medication costs without increasing use of other types of health services.

The results are less clear for the other classes of medications, perhaps due to the finding that some people were less likely to start any medication, including the first-line drug, under step therapy.

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