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MD Bill Aims to Restrict Drug Pricing Changes, Access Barriers

The Continuity of Care bill would prohibit payers from creating treatment access barriers such as prior authorizations in the middle of a care plan.

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A Maryland bill could help patients receive uninterrupted access to critical treatments, regardless of changes in their health payer plans by preventing payers from making unreasonable changes to drug prices and medication access.

The Continuity of Care bill would prohibit payers from eliminating drug coverage or shifting a medication to a higher cost tier prior to the end of the standard one-year contract.

The bill would also keep health payers from enacting barriers to treatment access, such as extensive prior authorizations, or placing all effective drugs on a prohibitive price tier.

According to the bill’s sponsors, these tactics are extremely burdensome for patients who go to great lengths to select the appropriate health plan at the start of each contract period. For patients managing a chronic illness, selecting an appropriate health plan is key to ensuring they will have access to all necessary treatments.

When payers change terms of the plan in the middle of a contract period – a practice that is currently legal in Maryland – patients have to go through an extensive and often time-consuming appeals process to regain access to that treatment. Patients may also have to switch to a less effective treatment until the end of the plan contract.

“It is simply unacceptable that health insurance providers can interfere with a patient’s treatment plan at any moment,” said Sharon Allison-Ottey, MD, Executive Director of the CoShar Foundation, one of the bill’s nearly thirty supporters. “We are thrilled that the legislature will take up this important issue to protect patients.”

The bill has also attracted the support of Maryland’s chapter of the National Alliance on Mental Illness (NAMI), which said limiting patient access to treatment is an especially pressing issue for patients managing chronic behavioral and mental health conditions.

“When patients face unnecessary burdens to obtain their medication it can lead to costly in-patient hospitalization and/or emergency room visits,” said Kate Farinholt, Executive Director for NAMI-Maryland. “The Continuity of Care bill will help keep Marylanders healthy, leading productive lives, by providing stable and consistent care.”

Healthcare professionals are grappling with prior authorization and health treatment access for patients on a national level, as well.

Led by the American Medical Association, a group of 17 industry stakeholder groups issued a set of guidelines for ensuring timely access to treatments when healthcare teams face prior authorization barriers.

“Utilization management programs, such as prior authorization and step therapy, can create significant barriers for patients by delaying the start or continuation of necessary treatment and negatively affecting patient health outcomes,” the group said.

According to the AMA and its partners, health payers need to reconsider their widespread use of prior authorization and other utilization management programs, working to make them more manageable for patients and their providers.

Health payers should work to ease administrative burden, be more transparent about prior authorization and drug formularies, ensure continuity of patient care throughout a plan contract, and root prior authorization decisions in clinical evidence.

Although prior authorization protocol is intended to control healthcare costs, AMA and other industry stakeholders argue that the practice does more harm than good. Prior authorizations are notoriously inefficient, the AMA concluded, and lack the transparency necessary for patients and providers to move through the process efficiently.

“Due to its widespread usage and the significant administrative and clinical concerns it can present, the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients,” the organization said.