In a preemptive move, the Academy is urging the U.S. Department of Health and Human Services to preserve patient choice as it develops its strategy for containing Part B drug costs in Medicare. The Academy during a cost-savings discussion with the agency earlier this month expressed unease with the possible pursuit of a "step therapy"-type policy.
In step therapy, physicians must begin patients' treatment with a lower-cost drug, before moving to a more- expensive option. We expressed to agency leaders our strong belief that step therapy — which has yet to be formally proposed — would be inappropriate in ophthalmology.
The Academy's delegation to Health and Human Services was led by David B. Glasser, MD, the Academy's secretary for federal affairs, and George A. Williams, MD, the Academy's president-elect. We were disturbed to hear that the Trump administration might consider testing “step therapy” as a means for de-incentivizing the use of high-priced Part B drugs.
Agency leaders pointed to the private sector's recent imposition of step therapy for retina drugs. We countered in follow-up correspondence with pointed examples of why such an approach is wholly inappropriate for ophthalmic Part B drugs.
Step therapy would create a quandary for our profession's treatment of age-related macular degeneration. The Academy doesn't believe that our low-priced available treatment — Avastin — should be mandated for therapy, since it is both off-label and compounded. Also, ophthalmologists are keenly aware that some patients respond better to other drugs. The failure of a mandated treatment at the low-price "first step" could result in lost vision.
Instead, the Academy suggested that Medicare raise its payment for Avastin to be more in line with what commercial payers' rates. Doing so would more equitably cover the true costs of certain drugs' administration. In addition, CMS should also waive co-payments for the lowest-cost option.
