CMS Decides to Put Treatment Decisions in the Hands of Insurers

August 14, 2018


On August 7, the Centers for Medicare and Medicaid Services (CMS) issued guidance giving Medicare Advantage (MA) plans (private insurance plans approved by Medicare that cover hospital and medical expenses) the option of applying prior authorization and step therapy for physician-administered and other Medicare Part B drugs (effective January 1, 2019) stating that this policy change will lower costs, improve quality of life, and ensure that patients receive the most preferred treatment. CMS did not identify how “preference” is determined but one can conclude that it is for the treatment that is most preferred by the Medicare Advantage payer/ insurer.

CSC is concerned that this new guidance will delay access to treatment, limit patient preference, and will not lower the cost of drugs.


What Are Medicare Part B, Prior Authorization, and Step Therapy?

Medicare Part B

Medicare Part B helps cover doctors' services and outpatient care. Historically, the majority of outpatient cancer care is covered under Part B, such as drugs that are given in the doctor’s office.

Prior Authorization

Prior authorization is a requirement that your physician must obtain approval from your health insurance plan before prescribing a specific medication or procedure. While the guidance references prior authorization, the new policy focuses on step therapy, which is a form of prior authorization.

Step Therapy

Step therapy policies, commonly referred to as “fail first” policies, require patients to try a therapy on a lower, often less expensive tier and “fail” at it (not respond, experience complications, etc.) before moving on to a higher tier (more expensive) therapy. When step therapy policies are put in place, patients may have to start taking a therapy that is different than what their doctor originally prescribed.


CSC’s Position

In alignment with CSC’s position on step therapy policies, CSC does not believe that allowing Medicare Advantage plans to implement step therapy for Part B drugs is good for patients. For cancer patients, step therapy policies have the potential to cause significant harm as they may delay access to therapies that are the most appropriate and most effective. Patients have differing responses to treatments and personalized medicine is offering more targeted options. It is critical that providers have the autonomy to exercise discretion in treatment recommendations, incorporating both clinical evidence as well as patient input through shared decision making.

CMS has framed this guidance as providing an “option of negotiating for Part B drugs in a way that lowers costs and improves quality of life” as well as “ensuring that patients receive the most preferred drug therapy,” yet it is not clear how either goal will be achieved, nor is it clear whose preference is taken into consideration, though one can assume that it is not the patient’s preference. Ultimately, implementing step therapy lessens the role that patient preference plays when making treatment decisions.

The new guidance essentially takes the treatment decision power away from the patient and provider and puts it in the hand of the insurer. Beginning in 2019, MA plans will have the authority to determine which drugs are best for patients. For therapies that are accessible via a retail pharmacy (paid for by Medicare Part D) and are also administered by a physician (paid for by Medicare Part B), the MA plan will have the power to determine which therapy a patient will try first. This is not okay.


What Can You Do?

This is a perfect example as to why it is important for us to come together to advocate for policies that protect patients. At the Cancer Support Community’s Cancer Policy Institute we advocate for access to affordable, comprehensive cancer care. The new policy will likely negatively impact vulnerable populations and we need to advocate to protect these vulnerable populations. To join us in our advocacy efforts please join our Grassroots Advocacy Network. Share your stories of delays to care.

For more information on CSC’s approach to the drug pricing dialogue please read our comments in response to the Trump Administration’s drug pricing blueprint to lower drug prices.