Currently, New Mexico is one of 31 states with no appeal process for patients forced to try – and fail with – several rounds of less ideal, and sometimes cheaper, drugs before insurance will cover the medicine deemed necessary for them by their physician.
That try-and-fail process is called step therapy and is common across the nation as a strategy for insurance companies, including those in New Mexico, to save money by requiring doctors to treat patients with less expensive drugs before paying for more expensive drugs – even if a physician knows the drugs won’t help or could even hurt.
“This is entirely backwards from how medicine is supposed to be,” Dr. Barbara McAneny, CEO of the New Mexico Cancer Center and president-elect of the American Medical Association, said Tuesday.
She said the problem physicians and patients have with certain step therapy decisions is that some patients have already tried and failed on the suggested first-step drugs or would be harmed by not immediately taking the prescribed, ideal drugs. That leaves them suffering on less adequate treatment or even worsening their conditions by prolonging efficient treatment with no recourse for appeal.
She said she supports a bill moving through the Legislature that would bring New Mexico in line with the 15 other states with laws allowing for an appeal process if a patient is denied his or her ideal drug.
Senate Bill 11, sponsored by Reps. Liz Thomson, D-Albuquerque, and Monica Youngblood, R-Albuquerque, and Sens. Gay Kernan, R-Hobbs, and Liz Stefanics, D-Cerrillos, would mandate a fast-track internal company appeal process in which a doctor can petition for a patient’s needed medicine.
If denied again, the patient could then file his or her own appeal with the state Office of Superintendent of Insurance.
The bill has passed two Senate committees and could be debated on the Senate floor as early as today. A House bill was also introduced, but it has not gained traction.