COA Statement on CMS Guidance Allowing Step Therapy in Medicare Advantage Plans

WASHINGTON, Aug. 7 -- The Community Oncology Alliance issued the following news release:

Today's decision by the Centers for Medicare & Medicaid Services (CMS) to allow Medicare Advantage (MA) plans to use step therapy for Part B drugs is a dangerous step towards the government dictating what cancer treatments seniors can or cannot receive. This guidance will subject seniors on Medicare with cancer to an absolute nightmare in accessing - or not - the evidence-based, individualized treatments that their trained oncologists prescribe.

Step therapy, which is also known as "fail first," forces patients and their physicians to try cheaper, often older, treatments before they are allowed access to state-of-the art, newer therapies, which are often more expensive. This is despite the recommendation of the treating physician who believes the cheaper treatment would not work.

Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. They leave patients at the whim of middlemen who are more concerned with their bottom lines than patient outcomes, side effects, and wellbeing.

For cancer patients, step therapy can not only delay the delivery of the care prescribed by their oncologists, but also leaves patients facing this life-threatening disease without access to the most immediate and life-saving treatments. Although CMS has tried to build in protections and an appeals process for patients who are stopped from getting the most immediate and appropriate cancer treatment, navigating those hurdles while dealing with cancer can be agonizing and is an unnecessary burden.

As COA noted in its official comments on President Trump's Blueprint, allowing middlemen to influence treatment decisions is particularly dangerous in cancer care because there are few therapeutic and generic-to-brand substitutes, so patients need uninhibited access to the therapies their oncologists prescribe.

"Cancer treatment is becoming more personalized and not all therapies produce the identical result from patient to patient. Having therapy options is imperative to successful treatment," said Jeff Vacirca, MD, FACP, president of COA and CEO of New York Cancer Specialists. "CMS' action is the antithesis of where personalized cancer treatment is going -- it's old school, cookbook medicine that treats every patient as one size fits all. It's telling me to effectively sit back and let some middleman make treatment decisions for my patients."

COA is also perplexed and concerned by the guidance put forth for sharing savings via gift cards. "Does CMS truly believe that Medicare seniors will be enticed away from their physician-recommended treatment with the promise of a $50 Amazon gift card?" said Ted Okon, executive director of COA. "Allowing middlemen to profit off of denying cancer patients needed medications is immoral and cruel."

While COA commends and supports the administration's efforts to lower drug prices and costs for Medicare and its beneficiaries, it cannot come at the expense of disrupting the sacred physician-patient decision making relationship. Middlemen should not be empowered to make or deny individualized, evidence-based treatment decisions for patients with cancer.