© Ashira Vantrees – USA TODAY NETWORK (OPINION: This piece expresses the views of its author(s), separate from those of USA TODAY). Used with permission. Link to original article can be found here: https://www.democratandchronicle.com/story/opinion/2023/07/19/ny-patient-transparency-wins-are-great-but-theres-more-work-to-do/70424128007/
Over the past several years, Aimed Alliance has worked with patient advocacy groups and lawmakers to help improve outcomes for health care consumers, but some of our toughest challenges remain. We are pleased to report that we are making progress in one of the nation’s most populous states — New York.
During the 2023 session, the New York Legislature passed two patient protection bills, one of which addresses serious concerns with step therapy policies. The New York Senate also passed legislation to create additional step therapy guardrails.
Step therapy policies are harmful to patients.
Step therapy policies require patients to try and fail on alternative treatments before the health insurance plan will cover the medication that was originally prescribed. As a result, treatments that may be most effective can be inaccessible to patients until other treatments are proven ineffective. Step therapy may also require patients to try and fail on off-label treatments, multiple treatments, and those that they have previously failed on under a different health plan. Patients may also be required to try and fail on a treatment for more than 30 days, forcing them to continue to experience symptoms without relief. Insurers claim that step therapy can control costs; however, studies have shown that requiring patients to “fail first” may actually increase long-term costs as a result of patients receiving ineffective treatments.
To address these concerns, the New York Legislature considered two patient protection bills during the 2023 session
- The Transparency Patient Notification bill strengthens the current step therapy law by requiring health plans to establish a written procedure that provides notice to consumers of an adverse step therapy determination. The notification must include the reason for the determination, instructions on how to file an appeal, information on alternative covered medications, and applicable clinical review criteria. Both the Senate and Assembly passed this bill, and it is awaiting the Governor’s signature.
- The Step Therapy Guardrails bill, which has passed the New York Senate but not the Assembly, creates new guardrails on step-therapy protocols, such as prohibiting patients from trying and failing on more than one medication and requiring health plans to uphold a step-therapy override for 12 months.
The New York Senate and Assembly also passed a third bill that will help patients receive the personalized treatments they need. Biomarker testing is a growing practice, particularly within cancer treatment. For instance, the American Cancer Society Cancer Action Network has reported “patients with certain lung cancer types who received biomarker testing and then a targeted therapy saw a 31% reduction in risk of death.” However, lack of coverage for this testing can make it inaccessible to thousands of New Yorkers.
- The Biomarker Testing Coverage bill requires health plans and Medicaid to cover biomarker testing for diagnosis, treatment, management, or ongoing monitoring of a patient’s condition when the test is supported by medical and scientific evidence. Both the Senate and Assembly passed this bill, and it is awaiting the Governor’s signature.
Next steps
To build on this progress in New York and hold health insurers accountable, there’s more work to do. We’re counting on Gov. Kathy Hochul to sign both the Transparency Patient Notification and the Biomarker Testing Coverage bills into law. We also urge the Assembly to pass the Step Therapy Guardrails companion bill next year. In addition, we urge lawmakers to pass two bills that, if signed into law, will make the state’s step therapy laws even stronger:
- A protected classes law, introduced in the state Senate and Assembly in 2023, would ensure that step therapy does not apply to necessary medical treatments for dermatology, gastroenterology, hematology, neurology, rheumatology, oncology, and ophthalmology.
- A reporting requirements law (also introduced in both chambers in 2023) would require health plans disclose to the Department of Financial Services non-confidential information regarding step therapy override requests and determinations on a website that’s accessible to the public. Making this information available would allow patients, providers, and policy makers to better monitor how step therapy law is being complied with and identify opportunities for improvement.
Stronger New York step therapy laws not only help patients in New York but can serve as a model for patient protection legislation in other states. These laws will help ensure that health care is in the hands of those who understand what’s needed best: patients and their health care providers.
Ashira Vantrees is counsel to Aimed Alliance, a national not-for-profit health policy organization.
Last Updated on August 3, 2023 by Aimed Alliance
