Step Therapy & Other Threats
Another threat, Dr. Worthing said, is the proposal to allow step therapy policies—requiring physicians first try therapies they believed are doomed to fail—in Medicare Advantage Part B.
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Explore This IssueDecember 2018
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Dr. Fahey said three trends—the reimbursement reduction for E/M, biologic drug infusion site access and coverage for viscosupplementation—are the top insurance issues threatening rheumatology.
Some payers have initiated policies with the goal of moving infusions from hospital outpatient facilities to other, less costly sites, such as a patient’s home or physician’s office.
Since 2015, Dr. Fahey said, the Insurance Subcommittee has talked to 10 different health plans about this change, advocating for patients’ access to a monitored healthcare setting for their infusions.
Dr. Fahey also said a growing number of commercial plans—mostly Blue Cross Blue Shield companies—have started to limit or eliminate coverage for viscosupplementation. The ACR has advocated continuing coverage, saying it’s a good option for patients who don’t respond well to other therapies.
Dr. Fahey reminded ACR members they can report insurance-related complaints to the subcommittee using a form on the ACR website.
At the state level, the ACR has been busy on issues regarding biologics, step therapy and pharmacy benefit managers, said Zachary Wallace, MD, MSc, instructor in medicine at Harvard and a member of the Government Affairs Committee.
Forty-five states have laws on biosimilar switching—nine were enacted in 2018—with most requiring notification to patients of the switch within five days and allowing providers to prevent substitutions by, for example, writing “dispense as written” on prescriptions.
The ACR’s policy is that if a switch happens, the patient should be notified within 24 hours. This year, Dr. Wallace said, the ACR helped prevent two states from creating substitution rules that require no notice at all.
On step therapy, seven states considered bills—and New Mexico passed reform—to bring policies closer in line with the ACR’s goal. Its hope is that step therapy rules will be eliminated. When they are in effect, the aim is to allow physicians to override step therapy, based on a patient’s history, according to a reasonable timeline and in a way that’s easily accessible, Dr. Wallace said.
Among legislative victories on pharmacy benefit managers, Arkansas brought PBMs under the authority of the insurance commissioner. In Rhode Island, the ACR helped defeat legislation that would have codified copay accumulators, which prohibit manufacturer coupons from counting toward deductibles, making drugs less affordable.
Also this year, the ACR introduced state rheumatic disease report cards, in which each state is graded based on access, affordability, and activity and lifestyle, Dr. Wallace said. Those are available on the Simple Tasks website.
Dr. Wallace said advocating at the state level can include meetings at state capitals and in the community, along with phone, emails, letters and using social media. He put in a special word about RheumPAC, the ACR’s political action committee.
“A lot of what GAC (Government Affairs Committee) does and a lot of what the ACR does for providers and patients really wouldn’t be possible if we didn’t put our foot in the door,” Dr. Wallace said. “And the way to do that with a lot of these issues is through donations and showing these [representatives of Congress] that we support them, and we need them to advocate on our behalf.”