Karen Ferguson: Legislature’s prescription drug bill threatens patient health

By Karen Ferguson

After a nearly 20-year career at Arthritis NW, one of the largest rheumatology clinics in the Pacific Northwest, I’m deeply disappointed to see Washington state advancing legislation that would switch patients from the medicine their doctor prescribes to less effective treatments. Should it be signed into law, Senate Bill 5532 will certainly save the government money, as fewer chronically ill patients are able to access their medications, but it will come at great cost to the most vulnerable patient communities in Washington state and the clinicians that serve them. I would expect draconian cost-cutting behavior from insurance companies and their corporate pharmacy benefit management networks, but not from the public servants that represent our communities in the legislature.

SB 5532 would establish a board of five unaccountable administrators who would be tasked with deciding which medicines the state will acquire and make available to patients through a so-called “upper payment limit.” Essentially, if the state deems a medicine too expensive, patients will be forced to move onto a cheaper drug in the same class. SB 5532 makes the false presumption that choice of medicine is “one-size-fits-all,” and incorrectly asserts all drugs in the same class work equally well for all patients with the same disease.

Clinicians who treat patients managing complex chronic illnesses know that nonmedical drug switching is as unsafe as it is absurd. Moving a stable patient to a different therapy in pursuit of greater cost savings is typical profit-seeking behavior for insurance companies and their corporate PBM networks; it’s frustrating to see Washington legislators contemplate formulary restrictions and nonmedical switching tactics.

Rheumatoid arthritis affects more than 1 million U.S. adults and nearly 1% of the entire world population. It disproportionately impacts women and can cause debilitating pain. Every patient is unique in their medical history and needs, and patients often try different medications in the same class before identifying the one that works best for them. Taking medicine away from patients will cause direct harm, while driving up other costs in the health care system. Patients who can’t access their prescribed therapeutics end up needing more invasive and expensive treatments over time.

By creating an “upper payment limit” for certain medications, SB 5532 would handcuff Washington pharmacists, health care providers, hospitals and facilities, which would no longer be able to administer certain drugs – no matter how life changing they might be for the patient.

If a health care provider typically purchases drugs from entities outside of Washington, they may be unable to access the medication at or below the Washington “upper payment limit.” This would cause providers to stop purchasing certain drugs since they would be underwater on the cost of the medication. We can’t expect clinicians to provide treatment at a cost less than what it takes to acquire and administer that medication.

If a patient desperately needs a prescription that’s been excluded from Washington’s approved list, they might have to travel outside the state for treatment, which is particularly burdensome for patients with mobility issues, or those who rely on mass transportation. While patients can file for a grievance waiver through their health plan to appeal determinations made by the board on a case-by-case basis, profit-motivated insurance companies still control the outcomes, and what constitutes medical necessity.

Further, we know grievance processes like these create structural barriers in accessing care. Most patients have their hands full managing their own condition while caring for their families and won’t engage in a lengthy appeal process to access medication their doctor had already prescribed. It’s unfair to place arbitrary administrative barriers between patients and the medicine they need.

While I agree greater transparency and fairness is needed in the drug supply chain, SB 5532 fails to address out-of-pocket costs for patients at the pharmacy counter and instead puts the burden on clinicians and communities to fill the gaps as resources get taken away.

Karen Ferguson is the founder of “Our Stories Rx,” an interactive storytelling platform that elevates community voices impacted by structural gaps in health care delivery systems. Ferguson lives in Spokane.