Utilization Management Getting an Overhaul in Washington State

“Going to the WA Advocacy Summit is always a privilege. Being able to effect change to our health care law is an amazing thing,” says Heidi Barrett, Arthritis Foundation Washington state advocacy chair and a Platinum Ambassador. “Knowing this change will make the lives of the 1.3 million adults and 6,100 children in Washington with arthritis better is a humbling experience.”

On February 20, almost 60 Advocates from the Arthritis Foundation, Crohn’s & Colitis Foundation and National Psoriasis Foundation joined forces in Olympia, Washington, to educate legislators and their staff about legislation that would reform utilization management. The WA Advocacy Summit consisted of a morning of advocacy training, education about the bill and the current environment at the Capitol, as well as social media advocacy. Advocates then had the opportunity to turn that training into practice and meet with their legislators and/or their staff.

In a recently published story in the Everett Herald, Heid’s son, Levi, spoke about his experience of being forced to go through utilization management protocols despite the required drugs causing him to vomit and weakening his immune system. Utilization management – including step therapy (or “fail first”) protocols and prior authorization is a set of formal techniques used by an insurance carrier or delegate of the insurer, such as a pharmacy benefit manager or third-party administrator. These techniques are designed to monitor the use, or evaluate the medical necessity, of appropriateness, efficacy or efficiency of health care services, procedures or settings.

The use of these programs often creates significant barriers to quality patient care, delaying treatment and contributing to negative patient outcomes. Utilization management protocols can lead to delays in access to the medications that offer the greatest potential medical benefit to people with arthritis. Because arthritis is a chronic, degenerative disease, delays in treatment can worsen disease progression and even cause permanent damage and disability. In some cases, patients may have no alternate therapy for an extended period if the drug initially prescribed was rejected.

House Bill 1879 would ensure that utilization management protocols are more transparent and standardized. Specifically, this bill would ensure that utilization management protocols are based on widely accepted clinical guidelines so that medical expertise, not cost, dictates requirements. In addition, HB 1879 would establish an exceptions process for patients if trying, or staying on, a medication would create a significant barrier to compliance, worsen a comorbid condition, is contraindicated or will decrease the patient’s ability to achieve or maintain reasonable function. Lastly, this bill would unify timelines for granting or denying submissions on utilization management to three business days for nonurgent cases and one business day for urgent cases, with no utilization management for emergencies.

In all, Advocates had more than 50 meetings, all taking place in less than five hours.

“After leaving the lobby day at Olympia, I felt so empowered,” says Courtney Bruce, Arthritis Foundation Platinum Ambassador. “I felt very positive about the meetings we had with the staffers and representatives. They were very responsive to information we were bringing to them. They listened intently to stories of our loved ones. It was a great experience.”

HB 1879 has passed the Washington House of Representatives by a unanimous vote and is currently making its way through the state Senate. Washington Advocates can take action by sending an email to their member of the legislature through the action center or by clicking here. We need your help!


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