Butler County lawmaker pushing to stop non-medical decisions that switch prescriptions mid-plan

A pair of state lawmakers want to stop mid-year non-medical switching by insurance companies in Ohio, which experts say can put patients at a higher risk for complications.

Ohio Reps. Sara Carruthers, R-Hamilton, and Dr. Beth Liston, D-Dublin, introduced House Bill 153 earlier this spring and it’s gaining support within the medical field and has garnered bipartisan House support. The bill would, among other things, prohibit insurance companies from switching which prescription medicines they would pay for during a health benefit plan year.

Carruthers said this practice forces a patient “to switch to a less expensive treatment for no medical reason, often in the middle of a coverage year.” But in the end, she said this could cost patients, and health plans, more money if patients cannot afford or have adverse effects to the different medication.

Liston, a professor of internal medicine and pediatrics at Ohio State University, said health insurers will claim they’ll need to raise rates if they cannot switch the types of prescriptions whenever they feel necessary.

“I am sure you are going to hear scare tactics from health insurers who will say if we take this ‘cost-saving tool’ away from them then they will need to raise the insurance rates and they will threaten businesses about increasing rates,” she said. “These scare tactics are wrong.”

Liston said it’s less expensive to pay for medication than a hospital stay due to adverse effects.

The Columbus Medical Association submitted testimony on the bill to the House Insurance Committee last week, signed by the organization’s chief executive, Dr. Robert Falcone, and its two public policy committee co-chairs, Dr. Stephanie Costa and Dr. William Cotton.

“Medication is not automatically interchangeable,” they wrote. “It is an all-too-common experience of our physicians that unintended consequences result with a patient’s chronic disease becoming destabilized due to this forced medication change,” they wrote.

Other medical professionals cite similar positions.

“These actions limit a patient’s access to care, and medical decisions are being decided by a health plan formulary instead of the medical direction provided to the patient,” said Shelly Wiest, vice president of Pharmacy Services at U.C. Health in Cincinnati.

Dr. Brian Evans, president of the Ohio Psychiatric Physicians Association, said it could take months, or even years, to find the right medication, or combination of medications and other treatments, for patients with a mental health condition.

“They have already gone through a period of trial-and-error, under the supervision and guidance of their psychiatric physician, trying several other medications,” he said. “If a patient is stable on a specific medication and it is helpful to their condition, it is devastating if their insurance company or pharmacy benefit manager suddenly makes a midyear formulary change.”

“The practice of non-medical switching can cause dangerous and harmful disruptions in continuity of care, resulting in adverse events that may require hospitalizations, visits to the emergency room, or other critical care.”

The bill also prohibits health plans from increasing a covered person’s cost-sharing burden for the drug; limiting or reducing drug coverage, including prior authorization requirements; and moving the drug to a more restrictive tier of the plan’s drug formulary.

Carruthers plans to talk with Insurance Committee Chair Rep. Thomas Brinkman if House Bill 153 can soon receive a committee vote.