Step Therapy Can Disrupt Cancer Treatment: Alyssa Schatz, DrPH, MSW

Coverage changes expected in 2027, persistent drug shortages, and utilization management are creating barriers to cancer care, according to Alyssa Schatz, DrPH, MSW, vice president of policy and advocacy at the National Comprehensive Cancer Network (NCCN).

Coverage Changes Add Administrative Burden

Medicaid community engagement requirements will likely add paperwork for patients in treatment, survivors with late effects, and caregivers, Schatz said. Their health care teams will also need to help with that process. She raised concern about people shopping for coverage who may later receive a diagnosis. Catastrophic and short-term plans carry “less comprehensive benefits, fewer protections for consumers,” she said.

In NCCN’s most recent survey, 100% of responding cancer centers reported at least 1 drug shortage, and 20% reported 5 or more. Schatz said current shortages are likely less severe than those of 2023 but still affect planning and mitigation. Most centers must still seek prior authorization for guideline-recommended alternatives. When the FDA lists a drug as in shortage, she said, those requests should move faster.

“If there’s a guideline-recommended alternative, and a drug is noted as in shortage by the FDA, we believe that those processes should be sped up to reduce further disruptions in care,” Schatz explained.

Prior Authorization and Step Therapy

Prior authorization is often not real-time or streamlined, which burdens clinicians and can delay care, she said. Step therapy is more concerning because it can “completely alter the course of your treatment,” particularly when cancer drugs are not interchangeable. NCCN supports models that use real-time tools to streamline guideline-adherent care.

Because NCCN guidelines are continuously updated, Schatz said, referencing them in legislation can keep statutes current as science advances. Every major payer in the United States uses them to determine coverage. She added that some guidelines were updated more than 10 times in a year, and she urged protection of federal research funding and peer review.