Beyond Illinois Borders: How Section 87 of the Health Care Protection Act Sets a Powerful Precedent for Patient Rights

The Illinois Health Care Protection Act (HPA) has rightly garnered attention for the significant improvements it brings to healthcare access and affordability for Illinois residents. However, one particular section, Section 87, holds the potential to create a ripple effect far beyond the state's borders, offering a powerful precedent for patient rights nationwide.

Section 87 of the HPA focuses on banning step therapy protocols. But its impact extends even further by requiring insurers to utilize treatment criteria developed by a third-party, non-affiliated entity in their utilization management (UM) processes. This crucial aspect has the power to inspire similar legislation and influence insurance practices across the United States, ultimately benefiting patients regardless of where they reside.

Excerpt from Illinois Health Care Protection Act, which will take into effect 1/1/2026.

Understanding the Burden of Step Therapy and the Problem of Biased UM Criteria:

Step therapy, also known as "fail-first," is an insurance practice that requires patients to try and fail on one or more less expensive medications or treatments before they can gain access to the medication or therapy initially prescribed by their doctor. While intended to control costs, this practice can have detrimental consequences for patients:

* Delayed Access to Effective Treatment: Patients may endure unnecessary suffering, worsening symptoms, and disease progression while cycling through ineffective treatments mandated by their insurance.

* Increased Risk of Adverse Effects: Less suitable medications can lead to unwanted side effects and complications, further impacting a patient's

health and well-being.

* Emotional and Psychological Toll: The frustration and anxiety of being denied the prescribed treatment can take a significant emotional and psychological toll on patients and their families.

* Increased Overall Healthcare Costs: Ironically, the delays and complications caused by step therapy can sometimes lead to higher overall healthcare costs in the long run due to disease progression and the need for more intensive interventions later.

Compounding the issues with step therapy is the potential for bias in the criteria insurers use for utilization management. When insurance companies develop their own UM criteria, there's an inherent risk that these guidelines may be influenced by financial considerations rather than solely focusing on the best clinical outcomes for patients. This can lead to denials of necessary care based on internal cost-saving priorities.

How Section 87's Third-Party Criteria Requirement Strengthens Patient Rights:

By mandating the use of treatment criteria developed by an independent, non-affiliated entity, Section 87 introduces a crucial layer of objectivity and clinical expertise into the utilization management process. This offers significant benefits for patients, both in Illinois and potentially nationwide:

* Reduced Bias in Coverage Decisions: Independent, third-party organizations typically base their treatment criteria on robust, evidence-based research and the consensus of medical experts, minimizing the influence of an insurer's financial incentives. This leads to more clinically sound and less biased coverage decisions.

* Increased Transparency and Accountability: When UM decisions are based on publicly available, third-party criteria, patients and providers gain greater transparency into the rationale behind coverage determinations. This can foster trust and increase accountability within the insurance system.

* Alignment with Best Clinical Practices: Non-affiliated entities are often medical societies or organizations dedicated to specific disease areas. Their treatment criteria are more likely to reflect the latest advancements in medical knowledge and the generally accepted standards of care within the medical community.

* Empowering Physicians' Clinical Judgment: When UM decisions are guided by objective, third-party criteria, it lends more weight to the physician's expert opinion and prescribed treatment plan, reducing the likelihood of arbitrary denials based on internally developed, cost-focused guidelines.

* Setting a National Standard for Objective UM: Just as the ban on step therapy can inspire other states, the requirement for independent UM criteria can set a new benchmark for how insurance companies should approach coverage decisions nationwide. It highlights the importance of separating financial interests from clinical recommendations.

The Ripple Effect of Objective and Patient-Centered Care:

Section 87 of the Illinois Health Care Protection Act, with its dual focus on banning step therapy and mandating independent UM criteria, represents a significant leap forward in patient protection. By ensuring that coverage decisions are based on objective, evidence-based guidelines rather than potentially biased internal policies, Illinois is championing a more transparent, accountable, and ultimately patient-centered healthcare system. This bold move has the potential to resonate across state lines, inspiring similar reforms and fostering a national dialogue that prioritizes the well-being and access to necessary care for all patients. The fight for equitable healthcare is a collective one, and Illinois has provided a powerful framework for others to follow.