New Medicare drug policy is a step down for seniors

A new policy from the Centers for Medicare and Medicaid Services prioritizes insurers over patients, and that’s wrong. Here’s how to fix that.
Published November 23
Updated December 3

Officials at the Centers for Medicare and Medicaid Services recently issued a shocking pronouncement. They’ve decided to prioritize insurers over patients.

The agency recently released new instructions to insurers that participate in Medicare Advantage, allowing them to require patients to take “the most preferred drug” on the market for their condition first, before trying any other treatments.

Unfortunately, “most preferred” is often merely a euphemism for cheapest. So even if a doctor has concluded, for sound medical reasons, that a different treatment would be more effective, an insurer can demand that a patient first try — and fail — with the “most preferred” drug. This process, known as “step therapy,” will delay treatments for cancer patients and other seriously ill seniors, putting their health — and their lives — at risk.

Step therapy is a blemish on the otherwise popular Medicare Advantage program, which offers seniors who opt in privately administered health plans. Coverage options can include the majority of beneficiaries’ health needs, including prescription drugs, physician, hospital, and outpatient services.

CMS’ new guidance will impede access to care for Medicare Advantage patients receiving medications administered under a doctor’s direct supervision, which fall into Medicare’s “Part B” category. These include infusion treatments for cancer and autoimmune diseases.

Step therapy can be downright cruel for patients battling chronic and painful conditions. Imagine suffering in agony for weeks, months, or even years trying out different treatments that your physician knows are unlikely to help. With each new drug comes a new set of side effects, but no noticeable health benefits.

Previously, a 2012 CMS directive banned step therapy for Part B treatments — and for good reason. Part B drugs are highly specialized. Doctors must take into consideration a patient’s diagnosis, lifestyle, medical history and more to find the best treatment or combination of medications.

Lifting this ban puts some of Medicare’s sickest beneficiaries in real danger.

Consider the cancer patients who rely on Part B for chemotherapy. Such treatment regimens are highly individualized — with some patients responding better to one drug rather than another.

To combat the disease effectively, doctors must find the most appropriate treatment as quickly as possible. That process can be challenging under the best circumstances. Step therapy requirements only add to those difficulties, compounding patient suffering.

In the time it takes to satisfy an insurer’s “fail first” requirements, a patient’s cancer could go from treatable to hopeless. That’s especially true for patients with fast-moving cancers. Those diagnosed with esophageal cancer, for instance, have just a 46 percent chance of surviving six months. For pancreatic cancer, it’s 27 percent.

CMS hastens to assure Medicare beneficiaries that they can seek exceptions in particularly pressing cases. But doing so can entail a multi-stage process of appeals. It’s an additional burden a patient in a life-or-death battle should never have to endure.

It’s no surprise that the medical community is overwhelmingly opposed to step therapy. The American Medical Association, American Society of Clinical Oncology, American Society for Radiation Oncology, and the American Society of Hematology have all condemned the CMS move as a threat to patient health.

Their denunciations are richly deserved. CMS’ new policy guidance puts insurer profits above the best interests of patients. Introducing step-therapy into Medicare Part B will prolong the suffering of America’s most vulnerable seniors.

Peter J. Pitts, a former Food and Drug Administration associate commissioner, is president of the Center for Medicine in the Public Interest.

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