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 CMS: Medicare Advantage Plans Can Require Step Therapy (Insurers can impose this form of prior authorization for Part B drugs next year) 

Medpage: The Centers for Medicare and Medicaid Services (CMS) will allow Medicare Advantage plans in 2019 to apply a "step therapy" approach to Part B drugs.

CMS made the announcement and issued a memo detailing the changes on Tuesday afternoon. There's just one problem. Step therapy is a form of prior authorization and physicians really, really hate prior authorization, viewing it as disrupting the patient-physician relationship and creating an unnecessary burden.

In step therapy, patients must attempt another similar but typically less expensive medication before they can be prescribed a pricier one.

CMS Administrator Seema Verma told reporters on a conference call that the new approach would "ensur[e] that patients receive the most preferred drug therapy first."

The new option for plans would also create a "level playing field" between Part B and Part D drugs, enabling plans to negotiate better deals for patients, she added.

Part B drugs are typically more expensive and often include biologic agents. They are typically administered by physicians in their office, whereas Part D drugs are those picked up at a pharmacy and self-administered.

Full article here.


Study Hall Call on Aligning Coverage for Dually Eligible Beneficiaries Using Default and Passive Enrollment

On July 31, the Integrated Care Resource Center (ICRC) held a Study Hall Call on Aligning Coverage for Dually Eligible Beneficiaries Using Default and Passive Enrollment. This webinar described opportunities and roles for states in implementing default and passive enrollment. It also featured speakers from two states – Arizona and Tennessee – that have supported seamless conversion in their Dual Eligible Special Needs Plans (D-SNPs) for a number of years. They discussed challenges and best practices, as well as how to share data with plans to help them identify newly dually eligible individuals. View webinar materials:

Additional materials referenced in the webinar include:


Health Data Management: CMS mulls Medicare requirement that providers share data with patients

The Centers for Medicare and Medicaid Services hopes to release a proposal requiring healthcare organizations to give patients their medical information.

Healthcare information technology remains far behind all other major industries and is an inefficient system plagued by a lack of health IT interoperability, according to CMS Administrator Seema Verma.

“Providers are in a 1990s time warp where doctors are faxing patient records, medical staff are manually entering results into EHRs, and hospitals are handing out data on CD-ROMs while the rest of the country is functioning on fully digitized, integrated data that informs decision making instantaneously,” Verma told the Office of the National Coordinator for HIT’s Interoperability Forum in Washington, a three-day conference that kicked off on Monday.

While the federal government has spent more than $35 billion to get providers to adopt EHR systems, the technology is making their work more burdensome and causing widespread physician burnout, contends Verma. As a result, she said “doctors are still recording their notes on paper, and they’re still faxing patient records.” Verma challenged the industry to make every physician office in America a “fax-free zone” by 2020.

Read the full article here.