In a video message played during the session, U.S. Rep. Michael Burgess, MD (R-Texas), chair of the House Energy and Commerce Subcommittee on Health and an obstetrician by training, told rheumatologists they have his ear.
“It is critical for doctors and specialists to be involved in policy as it is developed. Your voice is important. Your input matters,” he said. “I’ve been in your seat before, and together, I believe we can work to reduce burdens on rheumatologists, bring reforms that are necessary and improve patient care.”
Sean Fahey, MD, chair of the ACR’s Insurance Subcommittee, said three trends—a reimbursement reduction for E/M, biologic drug infusion site access and coverage for viscosupplementation—are the top insurance issues threatening rheumatology.
Several health plans have introduced policies to cut reimbursement for E/M services, when billed with Modifier 25—involving distinct services on the same day—by up to 50%, out of the belief that they’re paying twice for certain fixed costs built into the coding. The counterargument, Dr. Fahey said, is that the American Medical Association’s Relative Value Scale’s Update Committee has already addressed this overlap by reducing the value of the codes that are frequently billed with Modifier 25. So the ACR and other medical societies have opposed the policy.
So far, the large national payer Anthem has rescinded its policy, but UnitedHealthcare recently announced a policy to reduce the reimbursements, Dr. Fahey said.
On another front, some payers have been starting 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 to continue coverage, saying it’s a good option for patients who don’t respond well to other therapies.
Dr. Fahey reminded ACR members that 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.
