By: Eric Gascho, NHC Vice President, Policy and Government Affairs
Millions of Americans with chronic diseases and disabilities rely on drug therapies to treat their diseases, maintain their quality of life, prevent co-morbidities, and often to prevent recurrence of progression of their disease. The Administration has decided to move forward with a policy change that would allow Medicare Advantage plans to use step therapy. As NHC CEO Marc Boutin wrote in an August blog post, this is harmful to patient care because it allows providers to prescribe less expensive and potentially less effective medication options before “stepping up” to drugs that cost more and are known to be more effective.
For many people with chronic diseases, there are few therapeutically-equivalent drugs for treating their condition. Therefore, this policy change could mean asking patients to take a drug that is not designed to treat their specific health needs and could negatively impact their care.
One of our top policy priorities is making prescription drug therapies more affordable and accessible for patient populations. This policy change would affect millions of Americans, and so we ask that the Administration be mindful of the potential negative impact on beneficiaries and to implement safeguards to ensure patient care is not negatively affected.
In a letter to the Secretary of the Department of Health and Human Services Alex Azar, we strongly urge the Administration to accompany this policy with a set of patient protections including:
- Adherence to evidence-based treatment guidelines: Guidelines must be put in place to require step therapy protocols to follow clinical practice guidelines and best practices that have been vetted through the peer review process.
- Protection for mid-treatment patients: We support the approach to ensure patients who are currently using medication that has already been proven to work effectively would not have to change medications.
- Recognized standard of care: There must be a requirement to start step therapy with the recognized standard of care – even if that recognized standard is not the least expensive drug.
- A simple and expeditious exceptions and appeals process: Treatment for patients who need a drug higher in the step protocol should not be delayed by a lengthy appeals process.
- Full transparency and oversight: Medicare beneficiaries should know in advance of enrolling in a health insurance plan whether there is a restrictive step therapy clause.