The Trump administration recently proposed a major change to Medicare's prescription drug benefit. The misguided reform could deprive seniors of lifesaving medicines.
Specifically, the administration wants to allow the private insurers who administer Medicare drug plans to stop covering certain medicines and impose more access restrictions on the medications they do cover. The changes, contained in a proposed rule released this past November by the Centers for Medicare and Medicaid Services, would affect medicines in six "protected classes" — anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals and immunosuppressants.
Together, these drugs help patients beat back HIV, cancer, arthritis and more.
Medicare's drug benefit, known as Medicare "Part D," works wonders for American seniors. Nearly 85 percent of enrollees are satisfied with their prescription coverage. Since Part D was established in 2006, roughly 200,000 enrollees have lived at least one year longer thanks to the program.
The protected classes are a big part of this success. Federal law requires Part D plans to cover all medicines in those six classes. This requirement ensures doctors can prescribe whichever drugs are best suited to each patient.
But CMS has threatened to weaken these protections substantially. Under its'new guidance, patients could be pigeonholed into specific therapies regardless of their doctor's medical opinion.
For starters, insurers would be permitted to employ "step therapy" requirements for drugs within the protected classes. In this scheme, a patient must first try — and fail on — the cheapest available therapy before their insurer will subsidize higher-tier treatments.
Take depression, a disease from which an estimated 16.2 million adults suffer. There isn't a "one-size-fits-all" approach to treating mental illness. A popular antidepressant could curb depression and anxiety symptoms for the majority of beneficiaries. For a few patients, however, that same drug could aggravate symptoms, inducing gripping side effects like blurred vision, restlessness and even suicide.
Seniors, particularly those battling serious diseases, don't have time to waste on ineffective treatments. For some cancer patients, for example, finding the right antineoplastic to slow tumor growth from the start is literally a matter of life and death. Just six months after an initial diagnosis, gastric cancer patients have only a 43 percent survival rate.
Another facet of CMS' plan permits insurers to forgo covering protected drugs should their cost increase faster than the general rate of inflation. This is a significant shift from the current policy.
Profit-hungry insurers could stop covering crucial medications to save a buck. And seniors' health will suffer because of it.
Faced with fewer — if any — drug options, patients could be forced to pay out of pocket for recommended therapies. Others might resort to less effective, cheaper drugs that their insurance will cover.
Some could stop taking medicines entirely. This practice, known as medication non-adherence, is already responsible for 125,000 deaths and 10 percent of hospitalizations annually. It also costs up to $289 billion each year.
These examples underscore the need for doctors to prescribe whichever drugs make the most sense for their patients. This is why the protected classes were created in the first place.2 comments on this story
It's no surprise that patient advocacy groups oppose these changes. The National Council on Aging is concerned that "altering these protections could lead to overly restrictive formularies that could limit beneficiary access to vital, life-saving medications." The American Cancer Society's Cancer Action Network fears the change will "result in beneficiaries simply choosing not to fill (their) prescription, which could lead to poorer health outcomes."
They're right. Far from a glamorous transformation, CMS' changes risk the lives of millions of American seniors.