Part B change could lead to increased hospitalizations

THE CMS’ DECISION to allow Medicare Advantage plans to require patients to try low-cost generics before stepping up to more expensive therapies could have an unforeseen consequence: increased hospitalizations.

The CMS announced last week that MA plans can impose step therapy on Part B drugs starting next year. Step therapy allows a plan to determine whether patients should try a low-cost generic before working their way up to a costlier product if the initial treat- ment is ineffective.

Making this change could delay what providers deem to be the appropriate treatment for a patient, according to Onisis Stefas, vice president of pharmacy operations at Northwell Health.

“Unintended delays can lead to clinical inertia or a suboptimal clinical response in vulnerable populations,” Stefas said. “A potential unintended consequence of this burden is providers seeking care for their patients in the emergency department or hospital setting.”

Part B drugs tend to be intravenously administered in physicians’ offices and include chemotherapy, autoimmune drugs and vaccines. Oral drugs for kidney disease and intense nausea are also covered under Part B.

Doctors say they have been able to keep patients with chronic conditions out of the hospital because they can choose the most effective drugs. The new Medicare policy appears to take away that medical decisionmaking, ac- cording to Dr. Eric Wong, a neurologist and oncologist at Beth Israel Deaconess Medical Center.

Physician autonomy in Part B comes with risks that this new policy could mitigate, according to Jesse Breidenbach, senior director of pharmacy at Sanford Health. Hospitals don’t always know if Medicare will cover a medication for a certain indication if it does not align with the list of Food and Drug Administration-approved treatments, he said.

Dr. Rita Redberg, a cardiologist at the University of California at San Francisco, said she doesn’t agree that step therapy will lead to worse outcomes and increased hospitalizations. She regularly prescribes generics as the first course of treatment for her patients. “The FDA wouldn’t be approving a generic if it weren’t as effective as the brand name.”

Expanding step therapy will likely save Medicare money as drug companies will compete to have the lowest-price offerings, she said.