For
the American Medical Association (AMA) House of Delegates Special Meeting this month, the ACR has introduced and will lead two resolutions intended to protect rheumatology practices and improve patient access to treatments.
The AMA House of Delegates Special Meeting will be held virtually Nov. 12–16. During this meeting, the ACR’s delegation will advance its Resolution 214, Stakeholder Engagement in Medicare Administrative Contractor Policy, and Resolution 215, Pharmacy Benefit Manager Reform as a State Legislative Priority.
The ACR considers and introduces resolutions based on its positions and policies and the work of ACR committees and the Board of Directors.
Medicare Administrative Contractors & Local Coverage Articles
The ACR delegation introduced Resolution 214 on Medicare Administrative Contractor (MAC) policy because of the continued use by MACs of Local Coverage Articles (LCAs) to unilaterally issue policy changes that may have the effect of restricting coverage or access. One example is the decision to downcode, or reimburse administration of certain highly complex biologics at Medicare’s simple therapeutic administration rate.
With LCAs, MACs can make significant policy changes without any requirement to provide data, scientific justification or evidentiary review related to the decisions, any notice-and-comment period for stakeholder input, nor any opportunity for reconsideration. MACs continue to make downcoding changes through LCAs without having to provide stakeholders any scientific explanation of why only the simple therapeutic code is being allowed for those drugs or information about what decision criteria and data the MACs are using. These changes often provide no opportunity for reconsideration, despite evidence-based considerations showing how biologics’ high complexity and safety risks meet the definition for reimbursement under the complex chemotherapy codes. These changes have significant repercussions for providers’ ability to treat patients.
If passed, the ACR’s Resolution 214 would address these problems by having the AMA:
- Oppose policy changes through LCAs that could restrict coverage or access without the provision of data, decision criteria, evidentiary review and stakeholder engagement;
- Engage with the Centers for Medicare &Medicaid Services (CMS) to have the agency prevent MACs from issuing such changes unilaterally without such data and engagement of stakeholders;
- Immediately invalidate any LCAs that potentially restrict coverage and access and require a restart of processes including stakeholders; and
- Advocate to Congress for clarifying language that would reinstate a role for local Contractor Advisory Committees (CACs) in review processes going forward, addressing unintended outcomes of changes in 21st Century Cures Act that allowed local CACs to be left without a voice or purpose.
Joining the ACR’s Resolution 214 as supporting cosponsors are the American Academy of Allergy, Asthma & Immunology; American Academy of Dermatology; American Academy of Ophthalmology; American Society of Dermatopathology; Association for Clinical Oncology; Society for Investigative Dermatology; and American Gastroenterological Association.
Pharmacy Benefit Manager Reform
The ACR introduced Resolution 215, Pharmacy Benefit Manager Reform as a State Legislative Priority, to address the abusive pharmacy benefit manager (PBM) practices that continue to plague both providers and patients. Over the last few years, the rate of state-level PBM reform has slowed, but the recent Supreme Court decision in Rutledge v. PCMA has now granted states greater authority to regulate PBMs. It is imperative that states use this broadened authority to regulate abusive PBM practices.
During the pandemic, physicians and patients have seen more aggressive tactics by PBMs, with exclusionary formularies, mandatory drug switching, copay accumulator policies and white bagging becoming more common. These policies pose dangers to patients and threaten the integrity of the provider/patient relationship. Although PBM transparency will not solve these problems, it will provide policymakers and regulators with more insight into the motivations behind these policies.
Additionally, the ongoing COVID-19 pandemic has left patients more vulnerable than ever to the economic pressures associated with higher prescription drug prices. Policymakers must have the tools to analyze the role that PBMs play in increasing drug prices, particularly the perverse incentives created by the rebate system. It is imperative that the AMA leads on this issue to ensure that the interests of physicians are represented in future state-level PBM legislation.
The ACR’s Resolution 215 would have the AMA:
- Explicitly make PBM reform a state legislative priority;
- Draft model PBM legislation or adopt model legislation from other organizations;
- Actively advocate for the passage of PBM reform in state legislatures across the country; and
- Update its Health Care Reform Objectives and the AMA Vision for Health System Reform to reflect this priority change and the importance of effective PBM regulation.
The Association of Clinical Oncology joined Resolution 215 as a cosponsor.
Sequestration
The ACR is also co-leading Resolution 212, Sequestration, introduced by the Association of Clinical Oncology. This resolution would have the AMA prioritize strong advocacy in opposition to the application of sequestration to Medicare, including to drugs administered under Medicare. Medicare sequestration relief temporarily implemented earlier in the COVID-19 public health emergency is set to expire at the end of 2021, with a 2% sequester set to take effect on January 1, 2022. With additional cuts, including PAYGO, commencing on the same date, rheumatology practices face a total of 9.75% cuts to their Medicare reimbursement (the Medicare “cliff”). These upcoming cuts place an unreasonable burden on practices and severely threaten patient access to care as many practices will struggle to keep their doors open.
The ACR’s delegation to the AMA House of Delegates consists of Gary Bryant, MD (Delegate and Delegation Chair), Eileen Moynihan, MD (Delegate), Cristina Arriens, MD (Alternate Delegate), Colin Edgerton, MD (Alternate Delegate), Luke Barre, MD (Young Physician Section representative), Christina Downey, MD (Young Physician Section representative), and Rami Diab, MD (Resident and Fellows Section representative). The ACR appreciates rheumatologists joining the AMA and renewing their AMA memberships so this work may continue. Input on the AMA delegation’s work on behalf of rheumatology can be directed to [email protected].
You Can Help
ACR members can help these efforts to advance rheumatology issues by joining the AMA and renewing their AMA memberships annually. Rheumatology’s voice in the House of Delegates meeting is determined by how many ACR members are also AMA members, so every single person who is a member of both the ACR and the AMA adds to the strength of these efforts. Join or renew your AMA membership before the end of 2021 and receive membership benefits along with doing your part to help to advance rheumatology.
