The ACR’s delegation to the American Medical Association (AMA) House of Delegates (HOD) successfully advanced key rheumatology issues at the Interim Meeting of the AMA HOD in San Diego Nov. 15–19. Two main issues moved forward at the meeting were pharmacy benefit manager (PBM) transparency and patient protections from step therapy protocols.
At the meeting, the AMA HOD adopted an ACR-authored and led resolution on PBM transparency. Resolution 813, Public Reporting of PBM Rebates, calls for PBMs and state regulatory bodies to make rebate and discount reports and disclosures available to the public and the inclusion of required public reporting of rebates and discounts by PBMs in federal and state PBM legislation. Resolution 813, co-sponsored by the American Society of Clinical Oncology (ASCO), is now part of AMA policy and its advocacy agenda.
The ACR also helped lead an ASCO-authored resolution on step therapy that was passed at the HOD meeting. Resolution 815, Step Therapy, calls for the AMA to extend its advocacy for patient protections from step therapy protocols to all health plans. The previous policy, written by the ACR and advanced with several partners at a previous HOD meeting, addressed only Medicare Advantage plans. The following patient protections are now outlined in AMA policy for all health plans:
- Enable the treating physician, rather than another entity, such as the insurance company, to determine if a treatment fails to work for a patient;
- Exempt patients from step therapy when the physician believes the required step therapy treatments would be ineffective, harmful or otherwise against the patient’s best interests;
- Permit a physician to override the step therapy process when a patient is stable on a prescribed medication;
- Permit a physician to override step therapy if the physician expects the treatment to be ineffective based on the known relevant medical characteristics of the patient and the known characteristics of the drug regimen; if patient co-morbidities will cause, or likely cause, an adverse reaction or physical harm to the patient; or if step therapy is not in the best interest of the patient, based on medical necessity;
- Include an exemption from step therapy for emergency care;
- Require health insurance plans to process step therapy approval and override request processes electronically;
- Not require a person changing health insurance plans to repeat step therapy completed under a prior plan; and
- Consider a patient with recurrence of the same systematic disease or condition to be considered an established patient and, therefore, not subject to duplicative step therapy policies for that disease or condition.
Resolution 815 was introduced by ASCO in partnership with the ACR and was also co-sponsored by the American College of Gastroenterology, the American Association of Clinical Endocrinologists, the American Gastroenterological Association and the American Academy of Ophthalmology.
