Modern Healthcare: HHS Examining Insurer Policy Requiring Patients to Start Over on Step Therapy

This post originally appeared in Modern Healthcare on February 12, 2019. 

HHS Secretary Alex Azar said the agency is exploring cracking down on a practice insurance plans use to make a patient start over on step therapy if they switch plans. Azar's comments before the American Medical Association's Advocacy Conference in Washington on Tuesday comes as the agency is proposing allowing Medicare Advantage plans to apply step therapy and prior authorization to drugs sold in Medicare Part B and Part D. The practice has opposition from some patient groups who fear that the tools hinder patient access. 

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Azar said he was "disturbed to hear" of patients switching from one insurance plan to the next can be required to start over for a step therapy or "fail-first" regimen, but didn't say how prevalent the practice is in commercial plans. Step therapy and prior authorization require a patient to try a cheaper drug before moving on to a more expensive drug. 

Under the practice, a patient would have to start over on step therapy if they switch an insurance plan, even if the cheaper drug doesn't work.

"This is not just injurious to [the patient's] health, it is also penny wise and pound foolish," Azar said. 

Azar didn't say specifically if a regulation was in the works on the practice for Medicare plans. 

"We are looking at how we can address that issue now and we would greatly appreciate you bringing to our attention other issues and things like that," he told the room of physicians.

But Azar defended the agency's move to implement step therapy and prior authorization for Medicare Part B, saying that such negotiation tools are already available in private plans. 

"Bringing down these costs without blunt restrictions on patient access has got to involve pitting drug companies against each other and that means giving drug plans some power to steer patients towards one option before another," he said. "Any talk about lowering drug prices in Part D without pitting drugmakers against each other is really just hot air and empty promise."

Azar also pushed physicians to get more involved in a value-based system of care. He mentioned work this year on reforming and updating several regulations such as the Stark Law and care coordination around HIPAA. The administration is also requiring accountable care organizations to take on more risk in order to get payments for value-based care.

"We are very open-minded about what kinds of regulations need to be re-examined to give you das physicians on the front lines the freedom to deliver better value in our healthcare system," he said. 

HHS wants to enable providers to join a value-based system from "direct contracting for primary care to incentive payments to smaller practices, all the way up to large provider networks and hospitals taking on full risk," Azar said.

He added that the more risk a doctor or hospital takes on, the less they will hear from HHS. 

"The more risk that you as providers are willing to accept for driving better outcomes, the less we are going to micromanage how you do your work," Azar said. "We are going to be clear about what we want, but we are not going to dictate how."