Step therapy protocols “can both harm patients and undercut the physician-patient decisionmaking process,” the Texas Medical Association said in a letter urging the Centers for Medicare & Medicaid Services (CMS) to reconsider its recent decision to allow step therapy in Medicare Advantage plans.
The American Medical Association, TMA, and dozens of other state medical and specialty societies signed on to the letter, which responds to CMS’ announcement last month that it would rescind its prohibition on mandatory step therapy for Part B drugs beginning in 2019.
The letter to CMS Administrator Seema Verma said the most appropriate course of treatment for a patient depends on the patient’s unique clinical situation and the care plan the physician develops.
Insurers’ step therapy protocols require patients to “fail first” on certain treatments before the health plan will pay for other treatments that are potentially more appropriate. Step therapy protocols are particularly concerning when applied to physician-administered drugs, the letter says, as patients receiving Part B-covered drugs often have serious or life-threatening conditions. Cancer patients, for example, need to receive the proper personalized treatment as quickly as possible.
“Although the notification states that step therapy can only be applied to new prescriptions and administrations of Part B drugs, we have serious concerns about patients who will change Medicare Advantage plans being required to disrupt their current treatment to retry previously failed therapeutic regimens to meet step therapy requirements for a new plan,” the letter says.
AMA, TMA, and the others also noted that step therapy puts a significant administrative burden on physicians, who don’t have ready access to patient benefit information and formulary information.
“This lack of transparency makes it exceedingly difficult to determine what treatments are preferred by a particular payor at the point of care and places practices at financial risk for the cost of administered drugs if claims are later denied for unmet (yet unknown) step therapy requirements. … At a time when CMS has prioritized regulatory burden reduction in the patient-provider relationship through its Patients Over Paperwork initiative, it is our hope that another layer of administrative complication will not be added on to an already strained system,” the letter says.
CMS’ Aug. 7 letter announcing the change says allowing step therapy for Part B drugs “will help achieve the goal of lower drug prices while maintaining access to covered services and drugs for beneficiaries.”
Last Updated On
November 16, 2018
Originally Published On
September 17, 2018