Utilization Management & Reimbursement
Step therapy bills have been re-introduced in both the House (H.R. 2163) and the Senate (S. 464). This legislation requires Employee Retirement Income Security Act (ERISA) health plans to allow for reasonable overrides so physicians can use certain medications, helping relieve the burden placed on providers and patients.
We are awaiting re-introduction of bills on prior authorization and dual-energy X-ray absorptiometry (DXA) reimbursement, which had strong bipartisan support in the past Congress. The prior authorization legislation will protect patients in Medicare Advantage plans that delay or deny access to care. It also supports reporting back to the CMS how often Medicare Advantage plans approve or deny medications and services.
Additionally, we have seen some wins early in the state legislative year. Arkansas has passed step therapy reform, and Georgia has sent prior authorization reform to the governor. Utilization management reform legislation is on the move in California, Arizona, Oregon and Texas, while several other states have introduced bills that we are supporting. We expect additional wins as the year progresses.
How you can help: The Legislative Action Center contains pre-written letters urging utilization management reform.
Up Next
This May, we (virtually) visited Washington, D.C., to advocate for workforce expansion, step therapy legislation and provider solvency as we continue to practice during a pandemic. We are tracking a number of issues and would love to hear from you. Check out the ACR’s advocacy priorities and join us for a Hill Day in September. I look forward to having conversations with you about how advocacy and health policy affect your patients and your practice.
We need a seat at the table. Investing in RheumPAC allows for nonpartisan meetings with lawmakers working on issues that impact rheumatology.
A colossal thank you to the ACR’s Government Affairs Committee members, patient advocates and physician and interprofessional team member advocates for continuing to embrace virtual advocacy and ensuring another year of success. I am also very grateful to the ACR staff in D.C., Lennie McDaniel, JD, director of congressional affairs; Amanda Grimm Wiegrefe, MScHSRA, director of regulatory affairs; and Dan Redinger, manager of advocacy and policy affairs, who work in tandem with staff in our Atlanta office, Adam Cooper, senior director of government affairs; Joseph Cantrell, JD, senior manager of state affairs; and Rachel Myslinski, vice president of practice, advocacy and quality.
I hope you will enjoy some version of hanami (cherry blossom viewing) this spring.5
