Bill Tries To Lower Insurer Influence Over Patient Medications

Mar 23, 2015

A fight over patient access to name-brand drugs has made its way to the legislature.
Credit PatientAccessForFL.COM / Patient Access for Florida

A battle between the pharmaceutical industry, patients and doctors has made its way to the Florida legislature. At issue: whether patients should have to deal with alternative medications and how much say prescription drug plans have on treatment.


Most health care consumers may be familiar with the practice of getting the generic version of a medication. They’re often cheaper, and have the same effectiveness of name-brand drugs. Most of the time its not a problem. But there are certain conditions where the generic is not the best option. Some insurers require what’s called “prior authorization” before approving the name-brand medicine. And that’s the source of conflict Senate Bill 784 by  Don Gaetz, R-Niceville, is trying to address. Gaetz recounts a story he was told by a former employee who, along with her husband, was recently diagnosed with Hepatitis C:  

“We went to the Mayo clinic in Jacksonville," Gaetz says the woman told him. "They told us what we needed to do to manage the disease. We went to the health insurance company and they said, ‘no, no, no—you have to fail first with three other therapies'. So we went back to the Mayo clinic and the doctors said, ‘if you do that, it won’t work—and you may not be around if you fail first in all three therapies'.”  

The AIDS Institute's Jesse Fry is backing the bill.

“It just brings accountability to the process so that the insurance industry and the managed care industry don’t take control and interfere with decisions that should remain between the doctor and the patient," Fry says.

The AIDS Institute is part of a coalition of healthcare groups called Patient Access for Florida. Gaetz’s bill creates a decision review panel. It would penalize  insurers who override a doctors decision, and a patient is harmed.  For example—there’s no one drug that suppresses HIV. So the practice of treating AIDS and HIV is customized to the patient. Requiring a one-size-fits all approach says Fry, could be life-threatening:  

“The treatments are customized to the type of virus a patient is living with and its critically important for a person  living with AIDS to get just the right medication their doctor, through diagnostic testing, has determined is right for them," he says.

The practice of “failing first” has been most prevalent in managed care. But its defenders say it’s a safety-mechanism. Speaking before lawmakers Monday, Florida Association of Health Plans President Audrey Brown made a case against the bill.

She says the practice contributes to, “identifying inconsistencies when patients are on a number of medications prescribed by different providers. detecting improper utilization and having the ability to implement age and diagnosis edits….this is all in an effort to maintain patient health, as well as prevent drug abuse and fraud.”

Brown argues allowing the bill to go through could lead to wider, and possibly unnecessary use of brand name medications, which could drive up costs. Gaetz argues there’s no evidence of that. But the argument circles back to one question-- How much say should Health plans have in what’s best for a patient?

“It seems what we have is an opportunity of the people of Florida to be able to listen to their physicians, to have treatments….that deal with their specific illnesses," Gaetz says.

Pharmaceutical companies have backed the bill, because they make a lot of money from name-brand medications. Insurers and business groups trying to keep their costs down—oppose the legislation. And in the middle? Patients. Who sometimes have to fight to get the medications they need.