CMS said Aug. 7 it will give private Medicare Advantage plans more negotiating power over prices for Part B drugs, which are administered in physician offices and hospitals, in an effort to reduce spending.
In a recent Health Affairs blog post, researchers from Boston-based Tufts Medical Center examined CMS' decision to allow Medicare Advantage plans to use step therapy protocols for Part B prescriptions.
Here are five takeaways from the article on step therapy and how it could affect CMS' proposal:
1. Through step therapy, private health insurers that cover about 20 million Medicare Advantage customers can make those members try cheaper biosimilar drugs before using more expensive treatments.
2. "Health plans use step therapy protocols to optimize prescribing (and control costs) by requiring that patients try a cheaper alternative before gaining access to a more expensive option," the researchers write. "However, a concern is that 'fail first' approaches can impede access to important treatments and require patients to use therapies that previously proved ineffective."
3. The researchers used a database developed by experts at Tufts Medical Center to examine trends among commercial health plans' specialty drug coverage. Roughly a fourth of coverage decisions in the database include a step therapy protocol, or about 1,208 of 4,809 decisions.
4. Researchers found a wide variation in how often health plans use step therapy protocols when deciding whether to extend coverage for specialty drugs. The decisions range from 2 percent of the time to 49 percent. Researchers also found that of the 1,208 coverage decisions including a step therapy protocol, 63 percent require patients to step through only one therapy, while 37 percent require stepping through multiple therapies and 15 percent require three or more steps.
5. "The findings provide a window into the kind of step therapy protocols we might see in Medicare Advantage plans. The wide variation in how and when protocols are applied also suggests a lack of strong evidence underlying protocols," the authors said.
They continued: "Health plans face a formidable challenge in balancing access to effective but expensive specialty drugs and spending resources judiciously. Given the stakes, plans should better communicate the rationale and evidence base for their decisions."