PBMs, Step Therapy, and QPP Changes Among ASCO’s Priorities at AMA Meeting

November 15, 2019

ASCO's delegates to the American Medical Association’s (AMA) House of Delegates (HOD) will propose several resolutions during the policy-making body’s interim meeting, which will be held November 16-19, 2019. ASCO currently sends three delegates to the AMA HOD: Edward P. Balaban, DO, FACP, FASCO; Thomas A. Marsland, MD, FASCO; and Ray D. Page, DO, PhD, FACOI, FASCO. The society also has two alternate delegates to the HOD: Kristina L. Novick, MD and Steve Y. Lee, MD. ASCO’s Resident Fellow Section Delegate is Erin L. Schwab, MPH, BS, MD.

ASCO's resolutions aim to improve the delivery of cancer care:

  • Pharmacy Benefit Manager (PBM) Formulary Design: As a result of PBM negotiated rates, health plans often steer patients towards specialty drugs based on what is most cost-effective for the plan and not necessarily what will be most effective for the patient. In many cases, the medications in these “specialty drug” categories are set at the highest specialty benefit tier which is subject to the highest patient cost-sharing. Though PBMs design formularies to generate cost savings, it is unclear if patients see those savings. ASCO’s resolution calls on AMA to advocate for PBMs and health plans to use a transparent, value-based decision-making framework that includes applicable specialty clinical oversight when determining which specialty drugs to give preference on their formularies.
  • Step Therapy: Health plans' use of step therapy frequently reduces access to innovative and complex drugs that have been a lifeline for patients with chronic and life-threatening conditions. In June 2019, AMA’s HOD adopted a resolution calling for the Centers for Medicare & Medicaid Services (CMS) to ensure additional patient protections for step therapy in Medicare Advantage. ASCO’s resolution calls on AMA to advocate for patient protections around step therapy protocols in other health plans through state and federal legislation.
  • Quality Payment Program (QPP) & Electronic Health Records (EHRs): Earlier this year, CMS proposed changes to require clinicians to make patient health information (including laboratory and pathology data) available within one-day of receiving results, rather than the current four-day requirement. ASCO is concerned that this one-day requirement would limit physicians’ ability to use their judgment in determining how best to share test results with patients – particularly when those test results could cause significant patient distress. ASCO’s resolution urges AMA to advocate for guardrails around the “immediate” availability of all test results in EHRs and requests that AMA work with EHR vendors to allow for more flexibility in information sharing.

Additionally, ASCO will lead the HOD's Cancer Caucus, which provides a forum to address oncology-specific issues that are either being discussed or should be discussed by the HOD.

For more information about the AMA HOD and ASCO’s activities at its meetings, read our ASCO in Action brief on the AMA, listen to a recent ASCO in Action podcast, or read about the approved resolutions from the June AMA Annual Meeting.

Keep up with ASCO in Action for updates on the meeting, information on important policy decisions, and any potential impact on cancer care.