March 1, 2011

Chronic Pain Costs Debated

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Connecticut lawmakers are considering a proposal to give people with chronic pain faster access to higher-cost prescription drugs.

Today the legislature’s Insurance and Real Estate Committee holds a public hearing on a bill to limit step therapy in cases of chronic pain.  Step therapy requires patients to try lower-cost remedies first. Only after those fail to control their pain would more expensive measures be covered.

The bill focuses on prescriptions and does not address approval of procedures. It would ban policies from requiring patients to try cheaper prescription or over-the-counter pain remedies before being covered for other drugs recommended by a physician. The proposal allows the insurer to insist upon a “therapeutically equivalent generic drug.”

“We want the doctors treating the patients, not the insurance companies,” said Paul Gileno of Shelton, founder of the U.S. Pain Foundation. Step therapy often makes patients wait too long for relief, according to Gileno.  People can develop depression, lose time on the job and incur high co-pay costs from repeated visits to their physicians.

In 2003, Gileno broke vertebrae in his lower spine, damaging his sciatic nerve. He said that he waited eight months for coverage to be approved for the surgery he needed and was meanwhile directed by his insurer to undergo physical therapy so painful that it often caused him to pass out.

“I was one of the lucky ones,” said Gileno, adding that many pain patients wait for years before getting appropriate treatment.

“Doctors are in charge,” said Keith Stover, a lobbyist for the Connecticut Association of Health Plans, explaining that panels of doctors and pharmacists determine which therapies should be tried first.

“These are nothing more than, in our opinion, reasonable attempts to figure out the right treatment regimen for each person, the most appropriate medication delivered in the most cost-effective ways,” he said.

Without providing a formulary, a list of drugs prescription plans cover, pharmaceutical sales and marketing practices could play too large a role in prescription choices, he added.  Formularies are critical if the country is “in any way serious about controlling health care costs,” Stover said.

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