Step Therapy in Medicare Advantage Hurts Patients, Providers, Says Schwartzberg

April 6, 2019

Step therapy, which requires that patients try the payer’s preferred treatment before the one a physician recommends, is harmful to both sides of the doctor-patient relationship, according to Lee B. Schwartzberg, MD, medical director of the West Cancer and Research Institute, who spoke at the 2019 Community Oncology Conference, held in Orlando, Florida.

Step therapy, which requires that patients try the payer’s preferred treatment before the one a physician recommends, is harmful to both sides of the doctor-patient relationship, according to Lee B. Schwartzberg, MD, medical director of the West Cancer and Research Institute, who spoke Friday at the 2019 Community Oncology Conference, held in Orlando, Florida.

Schwartzberg, who also recently became chief medical officer for OneOncology, a national partnership of community oncologists, discussed the challenges of step therapy with Ted Okon, MBA, executive director of the Community Oncology Alliance (COA).

Okon and COA were among the first to criticize the August 2018 directive from HHS to allow Medicare Advantage plans to include step therapy as a cost-saving measure, calling it a “fail first” strategy.

“When it comes to step therapy, there are so many problems, it’s remarkable we stand for it,” Schwartzberg said. The practice, seen for years in conditions like diabetes, is questionable when treating a chronic disease, Schwartzberg said, but in oncology it’s particularly alarming. Cancer patients often do not have the luxury of time to wait for a therapy to fail before moving to the one a

physician preferred in the first place, he said.

One may assume that payers use step therapy to force patients to start with older, cheaper drugs or generics, but that’s not always true. The first drug a patient tries, “could be the one that’s the most profitable,” Okon said. At least 19 states have passed laws to curb step therapy, and more states are considering legislation, he said.

Schwartzberg said in some cases, step therapy is applied for supportive drugs, but in others, it is used for therapeutic drugs. “This is antithetical to precision medicine,” he said.

He offered examples where a patient was pushed to try a different drug even though the patient’s serum creatinine levels were already elevated and the substitute would increase them. Pharmacy benefit managers, or PBMs, “take a very narrow view of what the ‘cost’ is,” Schwartzberg said. “They don’t take into account the patient experience at all.”

An example includes different choices for filgrastim. Schwartzberg said he’s all for using biosimilars when they are indicated, but he has some patients who live far from his clinic, and each trip is 100 miles round trip for the patient and the caregiver. Some forms of filgrastim come in a prefilled, subcutaneous injection that the patient or caregiver can administer, but other forms do not.

Another challenge is variation among payers. Schwartzberg showed a slide showing different policies for denosumab, a subcutaneous injection used to treat bone problems in cancer patients, including those with solid tumors and multiple myeloma. He compared policies for Humana, the Blues, Cigna, Aetna, and UnitedHealthcare. Of the group, Aetna had the most expansive policy.

Humana requires multiple myeloma and patients with solid tumor cancers to try other drugs first, Schwartzberg said, but exempts prostate cancer patients from this requirement. UnitedHealthcare also requires patients to try an intravenous bisphosphonate, and once on denosumab, they can only take it for 12 months.

Schwartzberg said knowing what company name is on the insurance card doesn’t tell him much, because not all Medicare Advantage plans have step therapy, and typically patients have no idea their plans allow this. It’s not uncommon for his office to get an urgent phone call from a pharmacy that the health plan will not cover the therapy that Schwartzberg has carefully selected and discussed with the patient. He must default to what the plan allows.

This does not help build trust with patients, he said. “It’s so stress-provoking for patients. They say, ‘You prescribed this, now they are telling me this.’”

Schwartzberg said patients get what’s going on, and he won’t lie to them. “I tell them, ‘That’s not the drug that I would use, but we’ll try it.’”

Okon urged the oncologists in the audience to contact state and federal legislators on this issue. “There are a lot of members of Congress who understand this, and they are very against it,” he said.