On behalf of the ACR, I wish you happiness, prosperity and, above all, good health in this new decade.
Now that the holidays are behind us and 2020 has launched, the ACR’s dedicated volunteers and staff are working collaboratively to achieve many ambitious initiatives to ensure the College’s dynamic and bright future.
A few weeks ago in The Rheumatologist, I shared my thoughts about the ACR’s goals for the coming year and beyond. Ensuring access to effective and safe medications for our patients to control disease activity and restore and retain quality of life remains a pressing concern for rheumatologists and members of the interprofessional team. Although we see more medications than ever before being approved for the treatment of rheumatic diseases, our patients cannot benefit if these treatments are out of reach.
Some concerning coverage gaps and reimbursement challenges that affect our members and patients have arisen. In many states, we are seeing resistance from major payers not only to covering medications critical for our patients, but also to cover consulting services. What is the ACR doing to fight back on behalf of our patients?
The ACR Insurance Subcommittee (ISC), a branch of the Committee on Rheumatologic Care, has been working diligently with its staff to address urgent coverage and reimbursement issues that put the health of our patients and the fiscal viability of many rheumatology practices in jeopardy. The ISC is engaged in immediate, persistent advocacy to address these challenges with specific payers, and remains engaged with stakeholders on all sides of these issues.
Coverage for Physician-Administered Drugs
One ongoing issue that affects both rheumatology practices and our patients is coverage for many commonly prescribed, infusible, biologic drugs. Some payers have recently changed policies to require patients first fail self-administered formulations before providing coverage for infusible biologics. Despite advocacy efforts by the ISC against this change, many patients continue to face coverage delays.
At the ACR, we believe collaborative advocacy is a powerful tool. The ACR recently led a coalition of rheumatology organizations, including 25 state rheumatology societies, the Coalition of State Rheumatology Organizations (CRSO), the Arthritis Foundation, the Association of Women in Rheumatology (AWIR) and the National Organization of Rheumatology Managers (NORM), to advocate for a permanent cessation of a major insurer’s proposed fail-first policies. The ISC has also spoken directly to insurance companies and requested they provide advance notification to physicians before enacting any changes to coverage of these important therapies for our patients.
The ACR is staying fully engaged with payers about fail-first policies. We have agreed to assist one major insurer in developing a list of exceptions criteria that would help protect patients and support clinical decision making by ensuring patients can be excluded from the step requirements when necessary. We have also insisted that payers who enact fail-first policies grandfather coverage for any patients on existing therapy, so that they may continue with uninterrupted access to the medications they need to control their disease.