Urge UnitedHealthcare to Rescind its Harmful Mandates |
The National Infusion Center Association (NICA) has received reports from concerned providers and patients regarding several recently announced changes to UnitedHealthcare plans— step-therapy directives, specialty pharmacy mandates and non-medical switching policies. We are concerned that the proposed policy changes devalue member and provider choice, ultimately to the detriment of patients, and we ask that UnitedHealthCare reverse the decision to implement these changes:
- A new step therapy requirement through off-label rituximab for members with relapsing-remitting multiple sclerosis for whom the provider has prescribed Ocrevus.
- A new requirement for Ocrevus to be obtained through Optum Infusion Pharmacy or Optum Pharmacy, eliminating a practice's ability to buy & bill.
- A new process to steer members toward self-administered formulations for Orencia, Fasenra, and Nucala for reasons unrelated to health or safety, regardless of prescribed route of administration.
Specialty Pharmacy Mandate
The hidden costs associated with sourcing infusion drugs from specialty pharmacies make this model inviable.
- Mandatory specialty pharmacy acquisition will cause delays in treatment for members with significant health outcome, quality of life, and financial implications.
- Specialty pharmacy mandates increase the administrative burden on providers, increasing costs and ultimately restricting access to care.
- Specialty pharmacy mandates result in unnecessary waste.
Step Therapy
Step therapy mandates have a place in the utilization management toolbox but must be employed judiciously and responsibly. Healthcare is a business; however, as we are in the business of taking care of human lives, all decisions must be guided by principles of sound ethics. For step therapy policies to be ethical—and we are confident in our assumption that UHC is aligned in this objective— they should measure favorably against several core principles:
- First-step failure must not cause long-term harm.
- Cost savings must weigh favorably against long-term outcomes.
- First-step drugs must be clinically appropriate.
- The policy must provide patients with the best chance to meet their clinical goals.
Non-Medical Switching
NICA opposes any policies that aim to transition a clinically stable patient from their current therapy—one they have chosen with their provider in a shared decision-making process—to an insurer-preferred product for reasons other than health and safety. These utilization management strategies undermine the patient-provider relationship, devalue the years of training and clinical expertise of the prescriber, and are simply inappropriate mechanisms for payers to employ in an effort to control cost liabilities.
- Providers’ patient relationships and medical expertise make them the best source to decide the best of plan care with and for their patients.
- The ability to regularly communicate with patients during their visits for treatment is a critical touch point.
- Infusion providers perform critical assessments prior to administering medications in the office to identify contraindications to therapy.
- If patients are not receiving their treatment in the office, it is more difficult to determine the presence or source of treatment failure or side effects.
Conclusion
NICA strongly encourages UnitedHealthcare to reconsider its decision to supersede providers’ prescribing authority and clinical expertise by dictating the course of treatment and drug acquisition model for its members.