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Bill Would Let Physicians, Not Insurers, Decide on Strength of Pain Medications

What doctor prescribes would override limits set by health plans.

New Jersey residents could receive quicker access to powerful pain relievers under a bill advancing in the Legislature.

The bill, A-1832 would prevent insurers from requiring people to try more than one pain medication before they would be able to receive the medication that their doctors want to prescribe.

The bill pits advocates for doctors and patients, who say patients shouldn’t be denied powerful drugs like opioids when they need them, against insurers and employers, who emphasize the higher costs and the danger of exposing patients to potentially addictive drugs.

The measure targets a practice known as “fail first protocol” or “step therapy,” in which insurers require that less-expensive medications be tried first. This can lead to a series of less-expensive drugs being tried before the medication preferred by the doctor.

While the state already has rules to prevent step therapy, insurers still delay doctors’ recommended prescriptions by various means, including requiring prior authorizations from the insurer for doctors’ preferred medications.

Under the bill, once one pain medication has been tried and failed, prior authorization for the doctor’s preferred medication wouldn’t be required. In addition, the doctor would determine how long the medication required by the insurer must be tried before moving on to the doctor’s preference.

Timothy J. Martin, a Medical Society of New Jersey lobbyist, said the bill is the right approach for pain medication.

“It is one thing to ask me to fail in my allergy medication for period of time and have the sniffles more than I would normally like to, it’s an entirely different proposition to ask somebody to fail on pain medication before they can move on to the medicine their physician thinks would be more effective,” Martin said. “That provider is in a better position to understand the pain that a patient is going through” than an insurer would be.

The doctor’s preferred prescription would come at a price, both to employers and to the state government, opponents argued.

Sarah McLallen, vice president of the New Jersey Association of Health Plans, noted that prescription costs comprise 15 percent of rising national healthcare costs.

“Fail-first protocols and prior authorization are important tools in helping reduce and prevent the abuse of drugs like pain medications, and they’re also important tools to help reduce and prevent unnecessary costs in the healthcare system,” she said. She noted that the bill would cost the state an additional $5.8 million, because the state would be paying more for pain medication for public employees.

Pfizer’s pain drug Celebrex costs roughly $150 per month, while similar generics cost $10 to $15 per month, McLallen said. In addition, Celebrex’s price increased by 18.7 percent in 2011, while most the prices of most generics decreased.

“When you take away important quality and cost controls such as these, it only adds to the exponentially increasing cost of healthcare,” McLallen said.

Heather Cascone, senior manager of state government affairs for Express Scripts Inc., said allowing prescribers to determine the duration of time for trying medications would undermine an important tool for her company, which processes and pays prescription drug claims.

“Ultimately it’s our goal to keep prescription drugs safe and affordable,” Cascone said. She said pharmacy benefit manager companies like hers can make appropriate decisions based on both clinical safety and cost, without the influence of pharmaceutical manufacturers.

“Turning the authority for step-therapy initiatives over to the prescriber, we believe, would subvert the intent of these programs,” Cascone said.

Substance-abuse treatment providers support the measure, according to Randy Thompson of the New Jersey Association of Mental Health and Addiction Agencies Inc.

“Imposing step-therapy policies restricts access to medicine,” he said. “When patients are in need of medicine, they should not be denied that medicine that they need, or have to take a different medication that they don’t need.”

Thompson said patients should not have to go through unnecessary suffering, risk having their conditions get worse, and make unnecessary and expensive additional visits to doctors.

“We believe that medication should be determined between the doctor and the patient,” Thompson said.

Advocates and opponents of the bill also are sparring over whether it would prove harmful to prescription drug abusers.

Bill opponents contend that the risk for drug abuse would increase with easier access to opiates and other powerful pain drugs that are frequently abused.

Bill supporters argue that requiring patients to get unwanted and ineffective prescriptions will result in unused medications being left in medicine cabinets and open to being misused by people for whom they were not prescribed.

The bill was released by the Assembly Appropriations Committee on Dec. 13, when it was supported by six Democrats and one Republican and opposed by two Republicans. The Senate version of the measure has been referred to the Senate Commerce Committee.

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