Stop insurers from denying cancer care

OPINION:

When a 70-year-old man walked into my clinic last month with newly diagnosed chronic lymphocytic leukemia, the most common form of adult leukemia, the treatment decision was straightforward.

His symptoms were clear, and I prescribed the medication his condition required.

What should have taken days took more than a month, not because of any medical complexity but because his insurance company had other plans.

The insurer denied the prescription and demanded that he try an older medication first, one more likely to cause cardiovascular complications. This practice, known as step therapy, has sadly become routine in cancer coverage and amounts to insurer-mandated treatment sequencing that overrides physician-prescribed care.

My patient lost precious weeks as his cancer advanced, while insurers second-guessed the clinical judgment I have honed over 25 years treating blood cancers.

As a medical director for the largest community oncology network in the world, I see this problem every day.

President Trump recently criticized insurance companies for squeezing American families with rising costs. He is right to be frustrated. Still, the financial pressures he described don’t stop at monthly premiums. They extend to coverage restrictions that delay, redirect or outright deny cancer patients the treatments their physicians prescribe, often leading to increased health care costs.

Behind many insurance denials sits a pharmacy benefit manager. These companies act as middlemen, deciding which drugs get covered and imposing the rules doctors must follow. The three largest pharmacy benefit managers — CVS Caremark, Optum Rx and Express Scripts — are owned by major health insurance companies and control 80% of the prescription drug market.

Their business model depends on limiting patient access to maximize profits.

Insurers and their pharmacy benefit managers wield extraordinary power to delay, deny and dictate care. Step therapy protocols force physicians to prescribe treatments they know are inferior, waiting for patients to fail before insurers will approve what should have been prescribed initially. Prior authorizations that should take hours routinely take four to six weeks.

For cancer patients, treatment delays can have devastating clinical consequences.

Under nationally recognized cancer guidelines, forcing a patient to “fail first” (or demonstrate intolerance to another drug) can push the disease past the point where the originally prescribed therapy will be effective.

A recent national survey found that 97% of oncology professionals have seen patients struggle as a direct result of insurer-imposed step therapy. Yet insurers continue to do it, not because the clinical evidence supports it but because their contracts do.

Congress recently passed, and Mr. Trump signed into law, landmark reform legislation requiring disclosure of rebates and profits. This was a major victory that began to shine a light on an industry that has operated in the shadows for too long.

Health and Human Services Secretary Robert F. Kennedy Jr. and Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, are now tackling prior authorization barriers that delay treatment. This administration deserves credit for taking on powerful special interests that previous administrations ignored.

Disclosure alone will not solve the problem. We need policies that directly protect patients from harmful coverage restrictions by insurers and their pharmacy benefit managers. CMS must manage Medicare Part D formularies and enforce existing national cancer treatment guidelines that prohibit substituting certain cancer drugs for others. Insurance companies routinely ignore these requirements, forcing patients to switch treatments for cost reasons rather than medical need.

Beyond Medicare, Congress should pass the Safe Step Act, which has strong bipartisan support. This would establish commonsense guardrails that ensure step therapy protocols are based on clinical evidence, not cost considerations.

Despite these barriers, I remain hopeful. Innovation in cancer is advancing at a remarkable pace. Blood-cancer patients who once had limited options now have real hope for long-term survival. Yet realizing that hope requires everyone working together: researchers developing new treatments, physicians prescribing them, and policymakers ensuring patients can actually access them.

Congress and Mr. Trump delivered critical reforms to pharmacy benefit managers. Now they must build on that momentum. Passing the Safe Step Act and directing CMS to conduct appropriate oversight of Medicare Part D formularies would help ensure that treatment decisions are driven by medical evidence, not insurance company balance sheets.

• Dr. Sucharu “Chris” Prakash is director of quality services, medical director for Texas Oncology and past president of the Texas Society of Clinical Oncology. He has spent 25 years treating cancer patients and advocating for improved access to care.