The ACR’s delegation to the American Medical Association (AMA) House of Delegates advanced key issues for the rheumatology community at the AMA House of Delegates Interim Meeting, held in Honolulu Nov. 12–15. Among the key outcomes were strong support for and passage of the ACR’s resolution addressing the disruptive practices of third-party pharmacy benefit administrators; successful broadening of policies supporting protection of physicians and patients from civil and criminal liabilities in a post-Dobbs landscape; and the ACR’s successful bid to retain representation for rheumatology in the AMA House of Delegates and other AMA policy bodies as part of its five-year representation review. The ACR thanks all members who contributed to this effort by joining or maintaining membership in the AMA.
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Third-Party Pharmacy Benefit Administrators
On behalf of its members and the rheumatology community, the ACR is able to leverage its representation in the AMA House of Delegates by introducing for consideration new AMA policies and directives to take action. At this month’s interim meeting, the ACR’s delegation introduced Resolution 820: Third-Party Pharmacy Benefit Administrators, which shined a spotlight on the disruptive practices of these relatively new entities and advocated to bring them under existing pharmacy benefit manager (PBM) regulations, as well as future oversight efforts aimed toward PBMs.
The ACR rallied other organizations in support of its effort, and 17 other specialty societies and four state medical associations joined as cosponsors supporting the resolution: American Academy of Allergy, Asthma & Immunology, American Academy of Dermatology, American Academy of Neurology, American Academy of Ophthalmology, American College of Gastroenterology, American Society of Hematology, Association for Clinical Oncology, North American Neuro-Ophthalmology Society, American Gastroenterological Association, American Contact Dermatitis Society, American Society of Dermatopathology, American Society for Dermatologic Surgery, American College of Mohs Surgery, Florida Medical Association, Iowa Medical Society, Arizona Medical Association and Utah Medical Association.
The ACR’s resolution is now AMA policy and will direct the AMA to advocate that third-party pharmacy benefit administrators fall under the existing PBM regulatory framework and statutes, and that licensing, registration and transparency reporting should be required of these entities. It further will have the AMA advocate for third-party administrators to be included in future PBM oversight on state and federal levels.
The resolution successfully drew attention to harmful third-party administrator business practices that disregard patient health and quality of life. These third-party pharmacy benefit administrators, also considered specialty drug management organizations, operate similarly to PBMs without being referred to as such. Most currently provide and pitch their services to large employers’ self-funded plans. Their practices are highly concerning and disruptive to patient care and interfere in patient care decisions in a number of ways, including:
- Aggressive monitoring of biologics;
- Forcing switches to their preferred biologic or biosimilar;
- Enforcing treatment tapering without provider input;
- Limiting access to FDA-approved treatments; and
- Creating unnecessary disruptions and delays in treatment.
The organizations claim to use data and real-world evidence to identify cost-effective drugs for patients. Unfortunately, third-party administrators look for the lowest-cost treatment and take away the patient-provider decision for the best treatment for the patient. Because these organizations are newer to the healthcare landscape, they are not bound to PBM-related regulations or laws. In the existing PBM regulatory framework, third-party administrators are currently regulated at a state level. However, interest has increased at the federal level, including federal legislative hearings and a review of PBM business practices by the Federal Trade Commission.
The House of Delegates took action on many other topics impacting rheumatology. Significant debate and action addressed consequences of the Supreme Court’s decision to overturn Roe v. Wade. Importantly, working with others, the ACR’s delegation was able to advocate for broadening resolutions, including Resolution 223: Criminalization of Pregnancy Loss as the Result of Cancer Treatment, which initially focused on cancer care and protections for those clinicians, to pertain to all clinicians and patients. Because of these efforts, the AMA will now advocate that pregnancy loss shall not be criminalized for physicians or pregnant patients. It will also advocate that clinicians and patients should not be held civilly and/or criminally liable for pregnancy loss as a result of medically necessary care.
Additional successes were logged on resolutions to maintain access to methotrexate in the post-Dobbs era, to protect physicians practicing evidence-based medicine, and to promote state graduate medical education funding, international medical graduate and foreign medical graduate employment, among other issues impacting the rheumatology community.
Additionally, the meeting highlighted the AMA Recovery Plan for America’s Physicians, in which the AMA will focus on issues that have broad appeal across practice settings in rheumatology. Alternate Delegate Colin Edgerton, MD, noted, “The AMA is responsive to high-priority rheumatology concerns as highlighted by the AMA Recovery Plan for America’s Physicians. Chief among these priorities are fixing prior authorization and reforming Medicare payment.” Other focus areas of the AMA plan include supporting telehealth and reducing physician burnout. The ACR urges members to take action and urge Congress to avert the pending Medicare cuts by sending messages to lawmakers via the ACR Legislative Action Center.
Finally, thanks to ACR members who joined or renewed their membership in the AMA, the ACR completed a successful campaign to retain representation in the AMA House of Delegates and related critical policy bodies, including the AMA Relative Value Scale Update Committee (RUC) and AMA Current Procedural Terminology (CPT) policy groups. The ACR thanks all members who contributed to this effort. Maintain your AMA membership each year to take advantage of AMA member benefits and sustain rheumatology’s continued representation.
The ACR considers and introduces resolutions based on its positions and policies and the work of ACR committees and the Board of Directors. 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 Barré, MD (Young Physician Section representative), Christina Downey, MD (Young Physician Section representative) and Rami Diab, MD (Resident and Fellows Section representative). Input for the AMA delegation’s work on behalf of the rheumatology community can be directed to [email protected].
If you are experiencing specific issues with payers or have other practice concerns, the ACR offers individualized assistance to members of ACR and ARP. Write to [email protected] with your insurance, coding, billing, and other practice issues.