President Trump’s bid to revamp Medicare to lower drug prices for seniors is getting pushback from an unlikely source: Advocacy groups that represent patients.
Last month, the Trump administration rolled out two initiatives aimed at lowering drug costs for Medicare beneficiaries by allowing insurance plans to offer lower-cost alternative drugs in certain circumstances. But several patient advocacy groups argued that the efforts could backfire by creating new barriers to access for essential treatments.
The criticism is the latest levied at President Trump’s blueprint released back in May, which outlined a series of changes to Medicare that include allowing them to use some cost-saving strategies employed by private insurers. Some Democrats have charged that the blueprint’s changes to Medicare could raise costs for the program’s beneficiaries.
“You cannot guarantee that there will not be Medicare beneficiaries who will be paying more,” said Sen. Elizabeth Warren, D-Mass., to Health and Human Services Secretary Alex Azar during a Senate hearing in June.
Patient advocacy groups have blasted the new tools given to Medicare plans because they could possibly hinder access for patients with chronic conditions.
“It takes clinical decision making out of the hands of providers and puts insurance companies in control of patient treatment plans,” the American College of Rheumatology said in a statement referring to one of the plans.
In August, the administration proposed two new tools for private plans on Medicare to use to push patients toward more cost-effective medications and bypass pricier ones: Step therapy and indication-based formularies.
Under step therapy, an insurer initially will only cover a cost-effective drug for a patient. If that drug fails, only then does the patient move on to a more expensive therapy.
For example, under step therapy a patient would have to try a cheaper generic drug instead of a more expensive brand name drug.
The proposed policy would go into effect in 2019 and would apply to Medicare Advantage, a program that allows Medicare beneficiaries to use their Medicare benefit to buy a private plan. About one-third of Medicare beneficiaries have Medicare Advantage.
The policy would also only apply to drugs covered under Medicare Part B, which reimburses plans for drugs administered in physician settings, like chemotherapy or vaccines.
Medicare Part D is the program’s prescription drug plan that lets seniors buy products from pharmacies. Private plans represent seniors on Medicare Part D and negotiate with drugmakers for lower prices, but such negotiation has not been allowed for Part B drugs.
Currently, some Medicare Advantage plans use step therapy for Medicare Part D, but not for Part B.
But patient groups are angrily warning that the policies could cause barriers to care for people with chronic conditions. They are worried that if patients want pricey medications, they might not be able to get them at first.
“In some instances, utilization management tools like step therapy can create an extra hurdle for cancer patients to go through before getting the appropriate drug they need to treat their cancer,” said Chris Hansen, president of the American Cancer Society’s Cancer Action Network, in a statement last month. “Some patients may be required to try multiple therapies before they can access the one that was prescribed by their doctor.”
The network told the Washington Examiner that it is pushing the administration to add a robust appeals process to the rule or to scrap it altogether.
The administration’s other new tool is called an indication-based formulary, which expands the choices of drugs that a Medicare Part D plan can cover. A formulary refers to the list of drugs that an insurer will cover.
Currently if a Part D plan includes one drug on its formulary, it has to cover that drug for every single clinical condition it is approved by the Food and Drug Administration to treat.
For example, say a formulary covers a drug approved to treat arthritis, but FDA also approved it to treat another condition like Crohn’s Disease. The formulary would have to include that drug for Crohn’s Disease even if there is a cheaper alternative available.
The Trump administration argues that the provision prevents insurers from having more buying power with drug companies. It wants the indication-based formulary provision to be installed by 2020.
However, the American College of Rheumatology says that this proposal is even worse than step therapy.
“Unlike step therapy, which often delays effective treatments, this proposal would go even further and allow plans to remove therapies from the formulary altogether,” the college said in a statement.
It calls for the Trump administration to either scrap the proposal or clarify the process for allowing people to get exemptions.
“This process should be straightforward and not place an undue burden on the physician or patient in gaining access to needed medications,” the group said.
