ACR expresses concerns on step therapy in a recent meeting with HSS Secretary

Aug 17 2018

Yesterday, the American College of Rheumatology (ACR) met with U.S. Department of Health and Human Services Secretary Alex Azar for a productive discussion about the rheumatology community's concerns with a new policy that will allow Medicare Advantage plans to utilize step therapy in Medicare Part B. In the meeting, the ACR expressed concerns that this policy would delay rheumatology patients' access to treatments. David Daikh, MD, PhD, President of the American College of Rheumatology stated the following when asked about the meeting:

While we support the goal of decreasing the cost of medications, the ACR has long opposed step therapy and other utilization management techniques that undermine the clinical judgement of providers, delay access to needed treatments and put our patients' health at unnecessary risk."

"During the meeting, Secretary Azar expressed a willingness to provide clarifying language to Medicare Advantage plans that would further define the definition of 'grandfathering.' We hope this clarification will state that patients currently stable on their treatment will not be subjected to step therapy if they switch between Medicare Advantage plans. Such a clarification should also explain that if a patient has previously been through step therapy to arrive at an effective medication under a different health plan, they will not be subject to step therapy again when they switch plans. Similarly, if a patient goes into remission and is able to stop taking a drug, but later needs to go back on to treatment, they will not be subject to step therapy again. We believe the aforementioned clarification would be a positive step in protecting our patients' ability to continue with therapies that work, and urge HHS to move swiftly to provide that guidance. We also encourage HHS to provide additional information on what this policy will mean for patients transitioning into Medicare."

"We remain concerned that the provider burden will increase with this policy change but are encouraged by the Administration's willingness to accept input and proposals on how to reduce burden. Further, we appreciate the Administration's expressed willingness to engage with the provider community regarding the appeals process and the value of defining clinically appropriate treatment pathways as part of step therapy. We hope that the Administration will consider making the prior authorization and appeals process in Medicare Advantage more transparent and streamlined, as this is critical for patient access."

While we support the goal of decreasing the cost of medications, the ACR has long opposed step therapy and other utilization management techniques that undermine the clinical judgement of providers, delay access to needed treatments and put our patients' health at unnecessary risk."

"During the meeting, Secretary Azar expressed a willingness to provide clarifying language to Medicare Advantage plans that would further define the definition of 'grandfathering.' We hope this clarification will state that patients currently stable on their treatment will not be subjected to step therapy if they switch between Medicare Advantage plans. Such a clarification should also explain that if a patient has previously been through step therapy to arrive at an effective medication under a different health plan, they will not be subject to step therapy again when they switch plans. Similarly, if a patient goes into remission and is able to stop taking a drug, but later needs to go back on to treatment, they will not be subject to step therapy again. We believe the aforementioned clarification would be a positive step in protecting our patients' ability to continue with therapies that work, and urge HHS to move swiftly to provide that guidance. We also encourage HHS to provide additional information on what this policy will mean for patients transitioning into Medicare."

"We remain concerned that the provider burden will increase with this policy change but are encouraged by the Administration's willingness to accept input and proposals on how to reduce burden. Further, we appreciate the Administration's expressed willingness to engage with the provider community regarding the appeals process and the value of defining clinically appropriate treatment pathways as part of step therapy. We hope that the Administration will consider making the prior authorization and appeals process in Medicare Advantage more transparent and streamlined, as this is critical for patient access."