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Tag: Step therapy

  • Medicare Advantage: The numbers speak volumes

    Medicare Advantage: The numbers speak volumes

    The Center for Health and Democracy put together these facts illustrating the high cost we pay for Medicare Advantage, both financially and physically. In Medicare Advantage, our taxpayer dollars are not covering medically necessary care, as required, but rather end up in the pockets of corporate shareholders and executives. Consequently, the health and well-being of Medicare Advantage enrollees is at risk and thousands of enrollees die needlessly each year, according to one NBER report.

    • Revenue generated by UnitedHealth from taxpayer dollars in the Medicare
      Advantage and Medicaid program: $160 billion
    • Number of prior authorizations Medicare Advantage plans required in 2022: 46
      million
    • Amount that Big Insurance overcharges the government by in the Medicare
      Advantage program each year: $140 billion
    • Probability of dying after pancreatic cancer surgery with Medicare Advantage
      compared to with Traditional Medicare: 1.9 times more likely
    • Probability of dying after gastrointestinal cancer surgery with Medicare
      Advantage compared to with Traditional Medicare: 1.4 times more likely
    • Probability of dying after liver cancer surgery with Medicare Advantage
      compared to with Traditional Medicare: 1.4 times more likely
    • Profits raked in by Big Insurance, which run Medicare Advantage plans: $71
      billion
    • Compensation of the highest paid Big Insurance CEO in 2023: $22.1 million
      Percentage of Medicare Advantage plans requiring prior authorization for acute
      hospital stays: 98 percent
    • Percentage of times Traditional Medicare requires prior authorization for acute
      hospital stays: 0 percent
    • Percentage of Medicare Advantage plans requiring Step Therapy for medications
      covered under Part B: 46 percent
    • Number of times Traditional Medicare requires Step Therapy before covering the drug
      prescribed by your doctor: Never

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  • Medicare Advantage insurers increasingly use step therapy for cancer drugs, delaying care

    Medicare Advantage insurers increasingly use step therapy for cancer drugs, delaying care

    A study by Avalere reveals that health insurers are increasingly delaying and denying drugs to cancer patients through the use of step therapy, reports Noah Tong for Fierce Healthcare.

    The American Cancer Society Cancer Action Network (ACSCAN) released a paper that demonstrates Medicare Advantage insurers are weaving step therapy into their prior authorization requirements. Sometimes, enrollees don’t even realize it. Step therapy is a means by which insurers require patients to use a less costly treatment before receiving a more costly one, such as requiring an X-ray before approving a CT scan or MRI.

    Some say that requiring prior authorization for cancer drugs helps ensure safety. Prior authorization can also save patients money. But, what the Medicare Advantage insurers are doing is troubling. Patients and doctors are too often unaware of what the insurers are requiring. In particular, delays in treatment are concerning.

    Kisqali and Verzenio are two breast cancer drugs for which Medicare Advantage insurers often require step therapy. They won’t cover these drugs unless other less costly drugs are shown to be ineffective. One concern is “embedded step therapy,” which could hide an insurer’s use of step therapy. It might not be included in an insurer’s Part D list of covered drugs.

    In the year between 2023 and 2024, overall, Medicare Advantage insurers used step therapy more often for breast cancer drugs and hepatocellular carcinoma, according to the American Cancer Society.  Medicare Advantage insurers required step therapy as much as 95 percent of the time. They did not appear to require it for biosimilar drugs Kanjinti and Trazimera.

    The bigger insurers tend to require step therapy more of the time than the smaller insurers. If the issue is truly safety, they should be using step therapy with the same frequency.

    To date, the Centers for Medicare and Medicaid Services, CMS, which oversees the Medicare Advantage plans, has allowed insurers to decide for themselves when to use prior authorization. Some use it a lot more than others, at times delaying and denying urgently needed care inappropriately.

    Prior authorization determinations should be standardized across all Medicare Advantage plans. Without standardization, people cannot meaningfully distinguish among MA plans. Moreover, MA plans can wrongly deny or delay care with little if any accountability.

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  • Insurers denying some costly treatments patients need

    Insurers denying some costly treatments patients need

    Bob Tedeschi reports in Stat news on a growing trend by health insurers to deny some costly treatments doctors say patients need and require them to try less costly treatments first. It’s called “step therapy.” The goal of keeping health care costs down is reasonable, but the consequences for some patients can be serious. (Note: If you’d like your insurer to cover whatever reasonable and necessary care your doctor recommends, sign up for traditional Medicare if you’re eligible.)

    Step therapy at its best is arguably a good thing. There is no reason for patients to get newer treatments that are more expensive when older less costly treatments are available. But, step therapy presents a serious problem when insurers use it as a way to save money even if the older less costly treatments are not working. And, insurers are becoming “more aggressive” about making patients wait long periods before insurers will cover more costly treatments.

    In some cases, doctors know that their patients need particular treatments because they have tried other treatments that have not worked. Yet, that will not stop some insurers from requiring step therapy. As a result, many states have enacted legislation to block insurers from making patients try treatments that their doctors know won’t work.

    To be clear, no one is suggesting that insurers should pay for more expensive treatments when less expensive treatments work. However, insurers should not be requiring patients to try treatments when there are risks to so doing. For example, when patients switch insurers mid-treatment, the new insurer might require their doctors to drop their current course of treatment and retry treatments that have already failed.

    What is to be done? More transparency about insurer practices is critical, including how they define whether a treatment has failed. And, insurers should not be allowed to require patients to retry treatments that have already been determined to fail. Speedy appeals of insurer denials are also needed, especially when people’s lives and well-being are hanging in the balance.

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