Proposed rule on prescription drugs offers the wrong approach to seniors with complex medical conditions


It’s no secret that Medicare faces significant long-term funding challenges, and it’s appropriate that the Centers for Medicare and Medicare services look for ways to lower the cost of health care for seniors while preserving their access to life-saving, life-improving treatments.

But one change being considered by the Trump administration that will affect seniors on some Medicare Advantage plans is the wrong approach and threatens access to important care and treatments for seniors with complex medical conditions like cancer or arthritis.

{mosads}It’s called Step Therapy, and in short, it requires doctors and other care providers to begin treatment for a patient by using first the cheapest medication. It sounds sensible in theory, but in practice, it can be time-consuming and restrict a doctor’s ability to prescribe the medication he or she thinks is best to treat a senior’s condition.

Essentially, a patient has to “fail first” with a less-effective treatment than what their doctor would typically prescribe before escalating them to a costlier treatment. Doctors I’ve heard from agree that this can be a useful process – as long as it’s based on medical need, and not solely on cost-cutting.

The president’s proposal was the subject of a roundtable I hosted in my Eden Prairie District Office earlier this week. I brought in doctors, care providers, and patient advocacy groups to share their perspectives on how step therapy has been implemented and what it will mean for Minnesota seniors. What we heard was troubling.

One doctor discussed having to hire an additional nurse at each of his clinics, just to manage the additional paperwork associated with step therapy care. A urologist at North Memorial Health warned of cases where patients are eventually escalated to a different drug, but end up switching insurance plans and having to start the entire step therapy cycle over again.

Another patient spoke of growing up with arthritis, and how early on he was able to find the treatments that worked best for him. When he suffered a flare-up, he was immediately able to get those medications to prevent further complications. But under step therapy rules, he’d be forced to try drugs he knew were less effective, prolonging his suffering and exposing him to real health consequences.

This doesn’t just increase costs – it puts patients at risk as they are left waiting for the drugs and treatments they need. And it takes decisions about patients’ care out of the hands of doctors and puts it into the hands of insurance companies.

As Dan Endreson, of the National MS Society’s Upper Midwest Region succinctly put it, “When a patient loses functionality, you can’t get it back. When a drug fails a patient, that’s critical time that is wasted.”

I’ve also heard from cystic fibrosis patients that had to fail first on an inadequate medication were ultimately given the correct medication after several months, long hospital stays, and worse disease conditions simply to try and reduce costs.

Several states, including Minnesota, have passed laws liming insurer’s ability to utilize step therapy. These concerns are real, and so far they’ve gone largely unaddressed by administration policymakers in Washington. It’s why I’ll be writing the Health and Human Services Secretary Alex Azar to raise these issues – and to urge him to protect seniors from the costs and complications that will accompany step therapy regimes. It’s just one of the ways I’m willing to stand up to this administration when I think its policies will harm Minnesota’s seniors.

Paulsen is a member of the Ways and Means Committee. 

Tags Medicare prescription drugs Step therapy

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