Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney Aimed - PowerPoint PPT Presentation

Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney

Aimed Alliance – Who Are We? ▲ 501(c)(3) nonprofit organization that seeks to protect and enhance the rights of health care consumers and providers ▲ Conduct legal analysis, educate stakeholders, and advocate on their behalf ▲ Work to advance policies that protect consumers and doctor- patient relationship ▲ Prioritize step therapy because it represents unreasonable interference with health care decisions and could violate consumer protections if implemented in overly burdensome manner

Step Therapy – What is it? ▲ Payer-driven policy in which patient must try and fail on one medication before payer will cover the prescribed medication ▲ Health care payers often require patients to undergo step therapy to save money

Source: https://aimedalliance.org/tag/provider-perception-report-2018/

Source: https://aimedalliance.org/step-therapy-enacted-laws/ Current as of April 2019

Step Therapy – Common Approaches States often limit how step therapy protocols can be used. ▲ Policy levers: ▲ ▲ Clinical Practice Guidelines ▲ Clinical Review Criteria ▲ Uniform Paperwork ▲ Exceptions Process ▲ Timeline, Emergencies ▲ Already Failed on Same Medication ▲ Appeals ▲ Request Deemed Approved if Not Acted Upon ▲ Transparency Requirements New ideas? ▲

The Challenge ▲ Lack of knowledge among patients and providers about passage of laws and how to utilize these consumer protection laws to ensure patients receive medically necessary treatment and services ▲ Insurers can take advantage of this lack of knowledge ▲ Soft “no” vs. Hard “no” Source: aimedalliance.org

Engagement ▲ Public Education – Know Your Rights campaign ▲ Working 1-on-1 with patients and providers ▲ Determine which laws apply (employer, exchange, Medicare, Medicaid plan / state vs. federal laws) ▲ Advise on exemptions processes ▲ Threaten to file a complaint ▲ “Create your own headline” ▲ Leverage social media ▲ Speak to reporters ▲ Work with insurance commissioners, attorneys general, and state legislators

Engagement/Enforcement ▲ Specific wide-spread issues: ▲ Analyze the situation, research relevant consumer protections, communicate privately with the offending stakeholder(s) ▲ Seek voluntary change in behavior through education, legal arguments, public pressure, and political pressure ▲ Attorney General and Insurance Commissioner are a last resort

Questions? ▲ www.aimedalliance.org ▲ jwylam@aimedalliance.org ▲ @aimedalliance om Twitter

Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney Aimed - PowerPoint PPT Presentation

Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney Aimed Alliance Who Are We? 501(c)(3) nonprofit organization that seeks to protect and enhance the rights of health care consumers and providers Conduct legal analysis,

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Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney Aimed - PowerPoint PPT Presentation

Step Therapy Enforcement John A. Wylam, Esq. Staff Attorney Aimed Alliance Who Are We? 501(c)(3) nonprofit organization that seeks to protect and enhance the rights of health care consumers and providers Conduct legal analysis,

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