The Complexity of Cost in 2018
Drug prices are too high in the United States, period. Congress, President Trump, the media, insurers, businesses, patients and doctors agree. Although rheumatologists represent only about half a percent of U.S. doctors, we participate in this debate because of the relatively large costs incurred by biologics, and also the outcomes from rheumatic disease progression and disability. I can’t overstate how important it is that rheumatologists, rheumatology health professionals and our patients have a voice. We will, and you should, plan to exercise our first amendment rights to exert influence on our government to fix this price problem.
That said, it’s difficult for rheumatologists to single-handedly cut drug prices. The ACR takes strong positions, such as allowing Medicare to negotiate prices; publicizing the role PBMs play in increasing drug costs; and shepherding safe, effective biosimilars to compete in the marketplace as quickly as possible; however, current events are focusing our advocacy efforts. Right now, a few very important problems related to costs within Medicare are coming to a head and may turn the rheumatology world upside down quickly. I would like to explain two pressing issues fully:
- Biggest issue of the year: Medicare’s MIPS payment adjustments will now include Part B drug costs. This summer, groups will discover if they will have a bonus or a penalty of up to 4% in 2019. That bonus or penalty will be multiplied by the sum of the full cost of items and services, which will now include Part B drug costs, compared with prior, pre-MACRA adjustments that did not include Part B drug costs. These very high sums could magnify penalties so much that physicians stop providing Part B drugs to patients in 2019 and instead try to prescribe Part D (self-administered) drugs or, worse, they could threaten clinics’ financial viability. Meanwhile …
- MIPS performance scores will include costs for the first time in 2018. Cost will count as 10% of a provider/group score—a big jump from 0% in the first year (2017). And Medicare has communicated that the agency has not found an effective way to count costs for self-administered (Part D) drugs, but it will be able to count Part B costs. Thus, prescribing Part D drugs will not affect scores, but providing Part B drugs in the office will increase a provider’s perceived costs and, essentially, incur a penalty. Sound familiar?
The ACR’s Response
Your advocacy team has been working hard on these issues. Since early November, when it became clear that Medicare would not change the policy regarding Part B drugs in MIPS payment adjustments, the ACR has been pressuring Congress to fix the problem. In fact, I’m proud that the ACR has become a national leader on this issue. We’re hearing that a fix has bipartisan support, but it may not be as high a priority as other issues facing Congress today.