Varied use of step therapy among Medicare Advantage plans.

OBJECTIVES: First, to examine 7 large Medicare Advantage (MA) plans' use of step therapy. Second, to compare step therapy that health plans imposed in their MA and commercial (employer) drug coverage policies. STUDY DESIGN: Database analysis. METHODS: Using data from the Tufts Medical Center Specialty Drug Evidence and Coverage Database, we evaluated 7 large MA plans' use of step therapy in their Part B drug coverage policies. First, we determined the frequency with which different MA plans applied step therapy. Second, we determined the frequency with which plans imposed step therapy protocols across International Classification of Diseases, Tenth Revision, Clinical Modification categories. Third, we compared each step therapy protocol against each drug's corresponding FDA label indication. Fourth, we examined the consistency of step therapy protocols between the same insurer's MA and commercial lines of business. RESULTS: The frequency with which the included MA plans imposed step therapy ranged from 26.1% to 63.7%. Step therapy was most common for dermatology conditions (90.2%) and least common for oncology conditions (28.6%). On average, MA plans' step therapy requirements were consistent with the drug's FDA label indication 29.0% of the time. MA plans' and commercial plans' use of step therapy differed for the same drug-indication pairs 46.1% of the time. CONCLUSIONS: MA plans vary in the frequency with which they impose step therapy protocols in their Part B drug coverage policies. Moreover, insurers often impose different step therapy protocols in their MA plan and commercial plan offerings. Differences in plans' step therapy requirements may result in variability in patients' access to care within MA.

Variation In Use And Content Of Prescription Drug Step Therapy Protocols, Within And Across Health Plans.

Insurers limit the use of certain prescription drugs by requiring step therapy-that is, by allowing access only after alternatives have been tried and have failed. Using data from seventeen of the largest US commercial health plans, we examined step therapy protocols that determined patients' eligibility for specialty drugs and identified ten diseases that are often subject to that requirement. Overall, plans applied step therapy in 38.9 percent of drug coverage policies, with varying frequency across plans (20.6-57.5 percent). Of the protocols for the ten diseases, 34.0 percent were consistent with corresponding clinical guidelines, 55.6 percent were more stringent, and 6.1 percent were less stringent. Trials of alternatives not included in the clinical guidelines were required in 4.2 percent of protocols, and the consistency of protocols varied within and across plans. These findings raise questions about potentially overly restrictive step therapy protocols, as well as concerns that variability across health plans makes protocols onerous for patients and practitioners alike. The findings thus suggest the need for state and federal legislative initiatives to help ensure appropriate prescription drug use.

Changes in Utilization and Expenditures for Medicare Beneficiaries in Patient-centered Medical Homes: Findings From the Multi-Payer Advanced Primary Care Practice Demonstration.

BACKGROUND: Patient-centered medical homes are expected to reduce expenditures by increasing the use of primary care services, shifting care from inpatient to outpatient settings, and reducing avoidable utilization. Under the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare joined Medicaid and commercial payers in 8 states to support ongoing patient-centered medical home initiatives. OBJECTIVE: To evaluate the effects of the MAPCP Demonstration on health care utilization and expenditures for Medicare beneficiaries. RESEARCH DESIGN: We used difference-in-differences regression modeling to estimate changes in utilization and expenditures before and after the start of the MAPCP Demonstration, comparing beneficiaries engaged with MAPCP Demonstration practices to beneficiaries engaged with primary care practices that were not medical homes. Qualitative data collected during annual site visits provided contextual information on participating practices to inform interpretations of the demonstration outcomes. SUBJECTS: Fee-for-service Medicare beneficiaries attributed to MAPCP Demonstration practices or to comparison group practices. MEASURES: Medicare claims were used to measure total Medicare expenditures and utilization and expenditures for inpatient, emergency room, primary care, and specialist services. RESULTS: Despite the transformation of practices over the demonstration period, there was minimal evidence of a shift to more efficient utilization of health care services, and only 1 state saw a statistically significant reduction in total per-beneficiary expenditures. CONCLUSIONS: Although the MAPCP Demonstration did not have strong, consistent impacts on utilization and expenditures, this evaluation provides insights that may be useful for the design of future health care transformation models.