Using step therapy, pharmacy benefit managers get between cancer patients and oncologists

By Joseph Burns

Interference from health insurers is one of the biggest problems physicians face when prescribing medications, diagnostic tests, or other treatments for their patients. Too often, physicians or someone on their office staff need to get approval for all but the most routine remedies, drugs and clinical laboratory tests.

Requesting such approvals takes time that delays care and puts patients at risk for harm. Such delays also take time away from patient care and places an administrative burden on doctors and their staff members while insurers review the requests.

Frequently, insurers will deny such requests without offering any alternative. At other times, insurance companies will require a different course of treatment that the physician does not support. In recent years, health insurers have required physicians to use step therapy, meaning they’ll deny a certain medication and request that the physician prescribes another, usually lower-cost, drug instead.

Under most insurers’ step-therapy protocols, the patient must take the lower-priced drug for a certain length of time and must fail on the insurer’s lower-cost drug before the physician would be allowed to prescribe the medication requested originally. Or, if the patients fails on the lower-cost drug, the physician may be required to try another medication and the patient would need to fail on that treatment before getting the original drug the doctor prescribed.

In an earlier tip sheet, we covered the problems health insurers create with step-therapy programs. Now, pharmacy benefit managers (PBMs) are using step therapy and causing problems that are similar to the ones insurers cause. PBMs manage prescription drug benefits on behalf of health insurers, Medicare drug plans, large employers, and other payers, according to this report, “Pharmacy Benefit Managers and Their Role in Drug Spending,” from the Commonwealth Fund.

Health care journalists have covered this issue, and the Community Oncology Alliance has collected patient horror stories on a website under the heading PBMabuses.org. A nonprofit organization, COA is an advocate for more than 6,500 oncologists and other providers who work in the nation’s community cancer clinics.

The horror stories are just as you might imagine: a cancer patient will need a medication that the patient’s oncologist orders. But then when the order arrives at the PBM, someone working for the PBM will question the prescribing doctor about why the initial medication was prescribed. For oncologists, the intervention of a PBM does not always in the patient’s best interest.

This summer, the Massachusetts State Senate passed a step-therapy reform bill, becoming the 29^th state to introduce legislation seeking to regulate step therapy practices. “Patients with complicated illnesses should be receiving the medications that their doctors know they need, not repeatedly taking medications that they know to be ineffective just to help insurers save on costs,” said State Senator Julian Cyr, chair of the Joint Committee on Mental Health, Substance Abuse, and Recovery.

Writing for The Atlantic, Olga Kazan explained the problem last year in an article, “Invisible Middlemen Are Slowing Down American Health Care.” In this article, she explained how a PBM’s use of step therapy delayed care, creating problems for a cancer patient she interviewed. She described how a PBM and a specialty pharmacy used step therapy was akin to a “Kafkaesque journey” to getting the life-saving drug the patient needed. Due to the hurdles required, the patient couldn’t start taking the drug for nearly two months.

Specialty pharmacies process expensive drugs for patients with difficult conditions and often deliver medications by mail, Kazan explained. She also described PBMs as companies that negotiate drug prices with drug manufacturers on behalf of insurance plans, determine which drugs are covered and conduct the prior-authorization process for certain cancer drugs. Step therapy is an especially troublesome form of prior authorization.

Also, Kazan explained the problems that PBMs have introduced into the marketplace, writing that COA is one of several groups of doctors that accuse PBMs of delaying care and driving up drug prices. She quoted COA Executive Director Ted Okon as saying that PBMs benefit from keeping drug prices high.

“They [PBMs] get rebates from the drug companies and fees from pharmacies as a percentage of list prices, so the higher the drug’s price, the larger their payout,” she wrote. In addition, Kazan added that PBMs have said that their rebates from drug companies do not affect drug prices.

For health care journalists writing about PBMs and step therapy, Kazan’s article is a great place to start.