Insurer Hurdles Are Delaying Cancer Care: Physician Survey

Kerry Dooley Young

March 29, 2019

WASHINGTON — The majority of physicians who participated in a recent survey said they had witnessed insurers' gatekeeping techniques delay patients' access to oncology drugs, treatments, and tests, an advocacy group said.

The survey, released by the American Cancer Society Cancer Action Network (ACSCAN), focused on the drawbacks of insurers' so-called utilization management techniques.

The survey examined the impact of hurdles, such as prior-authorization requirements and dispensation limits, and also the impact of step therapy, according to which patients must be given less expensive drugs before insurers cover more costly ones.

Public Opinion Strategies and Hart Research Associates, which conducted the research for ACSCAN, said 200 primary care physicians and 201 oncologists participated in the survey. It was conducted in January 2019.

More than half of physicians surveyed — 56% — reported frequently or somewhat frequently having to wait for their patients' insurers to approve treatments, tests, or drugs.

Another 31% of survey respondents said these kinds of delays happen only "sometimes" in their practice, and 13% said they rarely or never occurred.

Similar results were found regarding responses to questions that asked physicians about the impact of insurers' policies on patients.

When asked whether their patients were unable to afford medicines for their cancer treatment or its side effects as a result of insurers' decisions, 43% said this happens very frequently or somewhat frequently. Another 42% said it happens sometimes, and 15% said it rarely or never occurred.

When asked whether their patients were unable to undergo tests because of insurers' decisions, 34% said this happens very frequently or somewhat frequently. Another 42% said it happens sometimes, and 24% said it rarely or never occurred.

Political Battle

ACSCAN is using the survey results in its campaign to prevent Medicare Part D plans from applying new hurdles to their payments for cancer drugs.

The US Department of Health and Human Services (HHS) proposed in November 2018 to revise a long-standing policy that requires Part D plans to include on their formularies all drugs in six classes of medicines. These are cancer treatments, anticonvulsants, antidepressants antipsychotics, antiretrovirals, and medicines for transplant rejections.

Delayed treatment can have life-threatening consequences, especially for cancer patients. Lisa Lacasse

"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 ACSCAN, in a statement about the survey results. "Patients need to have timely access to the best and most appropriate drugs to treat their disease."

ACSCAN timed the release of the survey results to coincide with a day of scheduled visits to Capitol Hill by opponents of the HHS plan. More than 50 patients, healthcare professionals, and caregivers representing 23 different organizations were slated to call on members of Congress, ACSCAN said.

The proposed Part D change has drawn criticism from many lawmakers. The drugmakers' lobbying group, the Pharmaceutical Research and Manufacturers of America (PhRMA), on March 22 posted a statement that included links to two bipartisan letters sent by members of the House to HHS Secretary Alex Azar in protest of his plan regarding the six protected classes of drugs.

In the statement, the PhRMA also displayed a bipartisan Senate letter to Azar that raised similar protest.

"Cancer patients often need highly personalized therapies and cannot afford treatment interruptions caused by insurers second guessing their doctors," wrote Sens. Marco Rubio (R-FL) and Kyrsten Sinema (D-AZ) in their March 13 letter to the Centers for Medicare & Medicaid Services (CMS).

Part of Plan to Control Drug Costs

The HHS has made its own arguments for the proposed Part D changes, pitching them as part of President Donald Trump's efforts to control drug costs.

The Part D protected class policy was never intended to be permanent, said Azar and CMS Administrator Seema Verma in a November 26 joint blog post.

Rather, the policy was meant to protect patients' access to medicines during the start-up of Part D in 2006. At that time, millions of beneficiaries were being transferred from established Medicaid drug coverage into the fledgling Part D plans.

Since then, the insurers who manage the Part D program have gained experience in handling appeals from patients who were initially denied medicine. Because of that, HHS and CMS have confidence that new limits could be applied to the protected classes of drugs, Azar and Verma said.

Currently, HHS and CMS want to allow Part D plans to exclude from their formularies drugs belonging to protected class for which price increases are greater than inflation. The proposed changes also include allowing step therapy for protected classes of drugs.

"Today, there are 63% more individual drugs in the protected classes than there were when the protected class policy was created — this means more competition that plans could leverage to provide high-quality options at a lower cost," Azar and Verma wrote. "But because under the protected class policy nearly every individual drug has to be covered, competition is thwarted."

Most Physicians Oppose the Plan

The ACSCAN survey found that most physicians who participated in the survey opposed the idea of expanding utilization management techniques into Part D. Still, some did back this idea.

In the survey, physicians were asked to imagine what would happen if Medicare Part D plans required step therapy and prior authorization for cancer medicines, set dispensation limits, and required mandatory generic substitution.

The survey asked the physicians whether they would oppose the use of these techniques in Part D.

Of the physicians who identified as Republicans, 20% favored the increase in utilization management techniques, and 74% opposed. Among Democratic physicians, 14% favored them, and 85% opposed them.

The physicians were asked whether adding these utilization management techniques to Part D would make it more difficult for patients to get their medicines.

Of the physicians who identified as Republicans, 76% said it would be more difficult, and 13% said it would be easier; 12% said it would have no impact.

Of the physicians who identified as Democrats, 84% said it would be more difficult, and 7% said it would be easier; 9% said it would have no impact.


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