Christine Jordan Sexton
It’s being called “The Right Place, The Right Time” bill by its supporters.
Opponents think the measure, SB 784, is the wrong bill at the wrong time.
Either way, it will be one of the most contested health care battles of the session and pits — once again — Florida’s largest physicians association against some of the state’s largest health plans and HMOs.
Filed by former Senate President Don Gaetz, the bill would prohibit HMOs and prepaid health plans from establishing prior authorization requirements, step therapy requirements, treatment protocols or other utilization management tool unless they are supported by “sufficient clinical evidence.”
Additionally, managed-care plans with prescribed drug formularies or preferred drugs lists would be required to offer a broad range of options for the treatment of diseases and, if feasible, must include at least two products in each therapeutic class.
“Too often insurance companies are inserting themselves into the middle of the patient/physician relationship and making medical decisions,” Florida Medical Association Executive Vice President Tim Stapleton said. “This bill will allow patients to get the medicine recommended by their personal physician. The bottom line is insurance companies have too much power and this bill brings much needed balance.”
The bill also establishes a seven-member commission that would be charged with developing and implementing policies and procedures for the review of prior authorization, step therapy or other protocols that limit — at the point of services — access to covered services, including diagnostic procedures, pharmaceutical services and other therapeutic interventions.
The commission would be housed in the Department of Health’s Division of Medical Quality Assurance. The majority of the members would be either medical or osteopathic doctors, must still be practicing and must have at least 15 years clinical experience. The Senate President would appoint two of the physicians, the House Speaker two and the governor one.
The two remaining members would be appointed by the governor. One of the two must have a doctorate in either pharmacology or pharmacy and must have at least 10 years experience, and the other member must have a doctoral degree in biostatistics or a related field and also have 10 years of experience.
Florida Association of Health Plans President and Chief Executive Officer Audrey Brown said health plans have their own formulary committees and that doctors and pharmacists are on those panels. Without that ability, she said, health plans couldn’t effectively manage their own pharmacy costs.
“I fail to see an instance where government bureaucracy performs a business function in a more effective or efficient manner than the private sector,” she said. “Let’s not import government-run insurance programs — which have well-documented shortcomings in other countries — to Florida.”
Step therapy and prior authorization was among the most hotly debated health-care issues of the 2014 session, enjoying strong support in the Senate, where Gaetz was president, but less support in the House. The issue was in play until the very end of session but did not pass.
