Press Releases

WASHINGTON, D.C. – Today, Congressman Brad Wenstrup (R-OH) and Congressman Raul Ruiz (D-CA) introduced The Restoring the Patient’s Voice Act. This legislation is designed to give providers increased autonomy in determining the care that is best for their patients.

Currently, when a physician prescribes a particular drug treatment for a patient, the patient’s insurance company may require them to try a less expensive treatment, or series of treatments, first, before they can have access to the drug originally prescribed by their physician. The patient is not able to try the second treatment until the first one “fails.” This protocol is known as “step therapy” and is understandably deployed by insurance companies as they strive to control costs while maintaining quality care.

Unfortunately, step therapy protocols often ignore a patient’s medical history, such as whether they have already tried certain drugs under a different health insurance plan, or if they have other medical conditions that might interfere with the drug’s effect. It may also not take into account whether a certain drug’s side effects will affect with the patient’s ability to perform their job, or if the patient would prefer a drug that has a different ingestion method or dosage form. While many insurance companies that utilize step therapy have a process for patients to receive exceptions, it can be unclear, resulting in excessive back and forth between the provider and the insurance company, and delaying care.

The Restoring the Patient’s Voice Act would require employer-sponsored health plans that employ step therapy to implement a clear process by which the patient (or provider) can request an exception. The exceptions process must be readily available on the website of the health plan and include an explanation of how to request an exception and any necessary forms or related contact information. The bill also specifies several instances in which a patient would be granted an automatic exception.

“While step therapy can guide patients toward less costly treatments, too often it serves as a roadblock to getting patients the treatment they truly need,” said Rep. Brad Wenstrup, DPM. “Instead of a one-size-fits-all policy that ignores a patient’s medical history or medical conditions and overlooks a doctor’s recommendations, we need a way to streamline the process for patients who require more individualized care. The Restoring the Patient’s Voice Act will make the process for requesting a step therapy exception faster, easier, and more transparent. The doctor-patient relationship is a cornerstone of quality healthcare and working to restore it in this way benefits all Americans.”

“The Restoring the Patient’s Voice Act of 2017 is a commonsense, bipartisan solution that will help ensure patients can access the care to treat their specific needs,” said Rep. Raul Ruiz, M.D. “As a physician, I know that each patient has unique needs and responses to different types of treatments or medications. This bill ensures a patient-centered focus to step therapy protocols. I was pleased to work across the aisle with fellow doctor, Representative Wenstrup, to introduce legislation that is a solution for patients across the country."

Similar legislation to improve the exemption process for step therapy has been introduced and passed in multiple state legislatures across the country. In Ohio, State Representative Terry Johnson has introduced legislation in the State House of Representatives. 

"I have been working on this common sense legislation in Ohio for some time now," said Rep. Johnson. "It is great to see my friend Brad carry this patient-centered policy forward on a national stage."

Support from Health Organizations:

 Ohio Osteopathic Association: “As a physician, I do not want to write a prescription for a medication my patient is unable to obtain because of cost,” said Geraldine N. Urse, DO and President of the Ohio Osteopathic Association.  “However, there are times when, because of a patient’s unique medical history, a particular medication must be prescribed.  Insurers are increasing their use of step therapy requirements, which vary from insurer to insurer and with procedures that change frequently.  These requirements result in physicians and staff spending hours attempting to obtain needed medications for patients.   I commend Congressman Wenstrup for introducing federal-level reforms for step therapy requirements.   Reforming step therapy will help achieve standardization, transparency and a streamlined process for physicians to override requirements get the medicines their patients need.”

Alliance for Patient Access: “AfPA thanks Dr. Wenstrup for his leadership and introduction of the Restoring the Patient's Voice Act,” said Brian Kennedy, Executive Director of AfPA. By offering a transparent process for overriding step therapy requirements, the bill will put patient care decisions back where they belong: between the patient and his or her physician.”

Mental Health American, Franklin County: “Without reforms, the use of step therapy requirements will continue to increase, which causes delays in treatment for patients,” said Kenton Beachy, Executive Director for Mental Health America Franklin County. “For patients with chronic conditions such as mental illnesses, or other diseases including cancer, multiple sclerosis, arthritis, or diabetes, delays caused by step therapy can mean serious health setbacks and increased costs as a patient’s condition could worsen.”

Ohio Foot and Ankle Medical Association: “Doctors care about cost effectiveness in the health care system,” said Jimelle Rumberg, Executive Director of the Ohio Foot and Ankle Medical Association. “In many cases, step therapy requirements help to keep medication costs under control.  However there are cases when given a patient’s unique medical history, a doctor must prescribe a medicine that fits that patient’s needs.  Step therapy can undermine this best judgment and cause delays in treatment.  Cong. Wenstrup’s bill will put in place reasonable controls that will help doctors and patients bypass step therapy requirements when necessary.”

American Medical Association: "Importantly, the bill specifies instances where coverage is automatically authorized, including when the treatment is expected to be ineffective due to characteristics of the patient or treatment, or previous failed attempts of the required drug.  By creating this process, your bill helps ensure that patients have timely access to treatment and reduces administrative costs to the health care system."

Background:

This legislation would require employer-based health plans that utilize step therapy to implement a clear process by which the patient or provider can request an exception, which must be readily available on the website of the health plan and include an explanation of how to request said exception. It would also require approval from the insurance company within three days; or 24 hours if the patient’s life is in danger. The exceptions specified in the bill include:

The required drug is contraindicated.
The patient has already tried the required drug under their current, or previous, health plan, and the drug was ineffective or caused an adverse reaction.
The required treatment is reasonably expected to be ineffective due to the known characteristics of the patient and the known characteristics of the treatment (i.e. ingestion method).
The required treatment is likely to cause an adverse reaction or other physical harm to the patient.
The required treatment is not in the best interest of the patient, based on medical necessity, because the patient’s use of such treatment is expected to decrease his/her ability to perform on the job.
The patient is already stable on the prescription drug selected by his or her provider.

# # #