Policy Resolution HHS-16-31

WHEREAS, patients, especially those with serious or chronic conditions, should be able to continue the course of therapy recommended by their physician;

WHEREAS, Health Plans and Pharmacy Benefit Managers (PBM’s) have implemented policies called non-medical switching that require patients to switch to cheaper, insurer-preferred drugs. These policies include making formulary changes that limit or restrict access to certain treatments and increasing out-of-pocket costs;

WHEREAS, a stable patient should not be required to switch treatments simply due to payer cost controls;

WHEREAS, studies have shown that patients with chronic conditions who have been stabilized on drug therapy and then switched to another drug face negative consequences, such as allergic  reaction or lack of response;

WHEREAS, nearly all health plans and PBMs in the U.S. switch patients between drugs as part of a utilization management program offered to employers and other customers, including states;

WHEREAS, switching a stable patient for non-medical reasons may be dangerous, is usually unnecessary, and rarely generates overall cost savings;

WHEREAS, out-of-pocket costs for patients can exceed 30 percent of the cost of primary care, specialist visits, and some medications, while average deductibles have increased by 150 percent over the past five years;

WHEREAS, despite protections in the Patient Protection and Affordable Care Act (ACA), consumers are still exposed to the whims of health plans and pharmacy benefit managers (PBMs) when it comes to health services being changed or denied;

WHEREAS, states may have statutory or regulatory protections for patients to continue health care if a health care provider is no longer with a health plan, very few states protect a patient when a health plan changes service or pharmaceutical coverage in the middle of the plan year; and

WHEREAS, the 2016 Letter to Issuers from the Centers for Medicare & Medicaid Services does require some health plans to increase transparency about what is covered, the federal government encourages but does not require health plans to temporarily cover non-formulary drugs as if they were on formulary and without imposing additional cost sharing when either a person changes plans or the plan makes a change in the middle of a plan year.

THEREFORE BE IT RESOLVED, it is critical to promote, support, and encourage continuity of care for patients, and benefit design should support treatment decisions that are driven by clinical  judgment and patient / physician decision making, not by costs to the payer, to promote long-term health;

BE IT FURTHER RESOLVED, that the additional legislative provisions should be examined to safeguard affordable and continuous patient access to health care services and treatments;

BE IT FURTHER RESOLVED, that additional legislative provisions should be established to ensure patient safety and knowledge of medications and insurance coverage; and

BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, the Vice President of the United States, members of the United States House of Representatives and the United States Senate, and other federal and state government officials as appropriate.

• SPONSOR: Senator Donne Trotter (IL)
  
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Co-Chairs: Representative Mia Jones (FL) and Senator Shirley Nathan Pulliam (MD)
• Ratified in Plenary Session: Ratification Date is December 4, 2015
• Ratification is certified by: Senator Catherine Pugh (MD), President