“Drug prices are going up in part because of the rebate system that PBMs use to negotiate with drug makers to get drugs on their formularies,” explains Dr. Worthing. “Our goals for 2018 are to start with proper definitions. We have asked Congress to have CMS properly define what a rebate is and what fees are in the system. It’s the first step toward promoting transparency; if you don’t define things first, PBMs can use a shell game to change the rebates and call it a fee.”
The Senate Health, Education, Labor and Pensions Committee has already conducted two related hearings and several committees in the House have introduced a bill to promote PBM transparency.
Without action, the cost-savings potential of biosimilars could be negated, Dr. Worthing says.
“When biosimilars come out and offer lower prices, the PBM system could derail that and prevent the very reason for biosimilars to exist from being successful,” he notes. “We are not only advocating for safe and effective biosimilars to be approved by the FDA, we are also advocating for a distribution system to get them to patients in a way that reduces prices and increases access to medications that patients need.”
Additional Priorities
Other priorities for 2018 include:
- Eliminating the physical therapy cap for Medicare beneficiaries;
- Ensuring that any legislation on healthcare reform prioritizes affordable and meaningful health insurance coverage for children and chronically ill patients;
- Preventing inappropriate non-medical switching;
- Addressing the rheumatology workforce shortage and maldistribution;
- Promoting insurance codes that adequately reimburse providers for cognitive care;
- Ensuring the availability of federal agency funding for rheumatology-related research;
- Promoting RISE as a tool to assist providers with MACRA;
- Streamlining prior authorization processes and forms; and
- Prioritizing bills that reform step therapy in states throughout the U.S.
How You Can Get Involved
There are a number of ways the ACR conducts its advocacy work, says Dr. Worthing, organizing “not only hundreds of meetings per year on Capitol Hill, we are also holding meetings and drafting letters and communications with coalitions of other provider and patient groups, and sending thousands of emails every year through the Legislative Action Center.”
Members can also contribute to RheumPac, the ACR’s nonpartisan lobbying arm.
The ACR’s efforts are “not designed to be partisan,” Dr. Worthing says. “This is almost always a bipartisan effort, and the ACR works with leaders on both sides of the aisle to ensure we best represent our members, our patients and our profession.”
