An ACR delegation will propose two new resolutions on issues affecting practicing rheumatologists and their patients at the American Medical Association Interim Meeting of the House of Delegates in Honolulu Nov. 11–14. These proposals promote transparency of pharmacy benefit manager (PBM) practices and the protection of private payer consultation codes.
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The ACR is introducing Resolution 810, Pharmacy Benefit Managers and Prescription Drug Affordability, with the support of the American Academy of Dermatology, the American Academy of Neurology, the American Association of Clinical Endocrinologists, the American Association of Clinical Urologists, the American College of Gastroenterology, the American Society of Clinical Oncology and the Infectious Diseases Society of America (IDSA). The resolution’s proposals “address the unreasonable and increasing cost of drugs for our patients,” says Gary L. Bryant, MD, FACP, associate professor of medicine at the University of Minnesota and the ACR delegation chair for the AMA meeting.
The ACR has spent years visiting legislators and regulatory agencies “to address multiple factors that impact the increasing costs of prescription drugs and access to them, including exorbitant new drug prices, rising costs of generic drugs, and restrictive third-party payer policies that deny or delay appropriate care for our patients,” he says.
Resolution 810 supports the AMA’s Truth in RX campaign for more transparent drug pricing and “focuses on the increasing impact that PBMs have on prescription drug pricing, access and affordability,” says Dr. Bryant. PBMs absorb drug manufacturer rebates in exchange for inclusion on formularies, but this increases patients’ out-of-pocket costs and spurs coverage denials, the resolution states.
“The central issue is the manufacturer rebates to PBMs, and the perverse incentives they cause, in which the patients are the losers. In addition, this practice places a severe administrative burden on physicians to attempt to act on behalf of our patients to get them their appropriate therapy,” Dr. Bryant says.
The resolution also calls for more education of legislators to promote policies that “improve the transparency in the rebate, pricing and formulary system,” he says. Patients’ drug costs are based on list prices, not what PBMs pay after these rebates, the resolution states.
The ACR also authored Resolution 819, Consultation Codes and Private Payers, which has been cosponsored by the American Academy of Allergy, Asthma and Immunology; the Infectious Diseases Society of America; and the state medical associations for Georgia, the District of Columbia and New Jersey. It calls for the AMA to discourage private insurance companies from discontinuing payments to physicians for consultation codes, and for insurance companies to engage in coding education if payments are discontinued due to coding errors or abuse.
The Centers for Medicare and Medicaid Services (CMS) discontinued consultation codes in 2010, a move strongly opposed by the ACR, says Dr. Bryant. Resolution 819 is a response to concerns from ACR members that some private payers plan to eliminate consultation codes, he says.
“Rheumatologists can best care for our patients by performing the record review, the interpretation of disparate, prior and current tests that lead to an accurate diagnosis and treatment recommendation, and often, coordination of care with several other physicians,” he says. “Elimination of consultation codes would then default to a system where the complex and time-consuming nature of these aspects of care are not acknowledged.”
The ACR joined the American Society of Clinical Oncology as a cosponsor of Resolution 225 in opposition to including Medicare Part B drugs in payment adjustments that would occur under the Merit-Based Incentive Payment System (MIPS). If passed, the resolution would have the AMA work with impacted specialties to actively lobby the federal government to exclude Medicare Part B drug reimbursement from the MIPS payment adjustment as part of the Quality Payment Program (QPP). Applying MIPS adjustments to the cost of separately payable Part B drugs would significantly and adversely exaggerate the magnitude of the bonuses and penalties under MIPS for medical specialties that routinely administer prescription drugs by infusion or injection, and put practices’ financial viability at risk.
For More Information
The full text of all the resolutions to be debated at the AMA meeting is available online. For more information on the ACR’s advocacy efforts, visit the Advocacy section of the ACR website.
Susan Bernstein is a freelance journalist based in Atlanta.