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Patient and provider advocates urge the administration to withdraw proposed changes to Medicare Part D drug coverage

​ACS CAN survey finds that utilization management is delaying cancer care in private plans, and respondents oppose allowing those same tools to be used in Medicare

A new American Cancer Society Cancer Action Network (ACS CAN) nationwide survey of cancer patients, caregivers, and doctors details the negative effects insurance utilization management policies in private insurance have had on patient care, and what those policies could mean should proposed changes to Medicare's Part D's "six protected classes" prescription drug coverage policy go into effect.

They survey shows that 1 in 3 (34%) cancer patients and more than half (56%) of doctors reported having to wait for an insurance plan to approve a cancer treatment, test, or prescription drug because of utilization management policies. The most common policies doctors encountered were prior authorization (96%), mandatory generic substitution (90%), quantity limits on prescription drugs dispensed (89%), and having to use a lower-cost drug first in what's often known as "fail first" or "step therapy" (88%).

Patients and caregivers reported that utilization management requirements like step therapy and prior authorization delayed their care, increased their stress and frustration, contributed to worse outcomes, and cost them more out of pocket. Doctors reported that these requirements made it harder for them to treat patients, delayed treatment, and were time consuming.

Currently, Medicare Part D plan sponsors are required to cover all or substantially all drug therapies in the designated six protected classes, which cover drugs for cancer, epilepsy, HIV/AIDS, mental illness, and organ transplants. However, last November the Department of Health and Human Services (HHS) announced a proposal to allow health plan administrators to extend the use of utilization management tools, like pre-authorization and step therapy, to protected class drug therapies.

"These findings clearly show utilization management is negatively impacting cancer care. Delayed treatment can have life-threatening consequences, especially for cancer patients, and is exactly why Medicare's six protected classes were created in the first place," said Lisa Lacasse, president of ACS CAN. "Patients need to have timely access to the best and most appropriate drugs to treat their disease."

More than 50 patients, providers, and caregivers representing 23 different organizations took to Capitol Hill on March 28 to ask lawmakers to oppose the administration's proposal. 

According to the survey, most cancer patients, caregivers, and physicians oppose all the most common utilization management techniques, especially prior authorization (60% patients, 84% doctors), and having to take a lower cost drug (step therapy) first (68% patients, 78% doctors).

"Targeted cancer therapies with no clinical equivalent are coming onto the market with increasing frequency, but they won't do any good if patient access is delayed, which could threaten the effectiveness of the therapy itself," said Lacasse. "Patients need to be heard on this critical issue. We call on Congress to deliver a strong message to the administration to withdraw these proposed changes."

The survey of more than 400 patients, caregivers and providers was conducted by Public Opinion Strategies and Hart Research Associates in January 2019. Read more about it here.

Read the full survey memo:

The patient and provider groups engaging lawmakers included: AIDS United, American Cancer Society Cancer Action Network (ACS CAN), American Society of Clinical Oncology (ASCO), American Society of Consultant Pharmacists (ASCP), American Society for Radiation Oncology (ASTRO), Alliance for Patient Access, Cancer Support Community, Colorectal Cancer Alliance, Epilepsy Foundation, Hepatitis B Foundation, International Myeloma Foundation, Lung Cancer Alliance, LUNGevity, Lupus Foundation of America, MAPRx Coalition, Melanoma Research Foundation, Mens Health Network, Mental Health America, Movement Disorders Policy Coalition, National Alliance on Mental Illness, National Ovarian Cancer Coalition, National Patient Advocate Foundation, and the Oncology Nursing Society.

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