It’s May, and soon, most state legislatures will be adjourning for the remainder of the year. Joseph Cantrell, JD, senior manager of state affairs for the ACR, who tracks the progress of state and federal patient care legislation, reports that several states saw solid gains during 2018 state sessions, which typically run from January to May. With the help of the ACR’s Affiliate Society Council (ASC), four more states passed biosimilar substitution laws, bringing the current total to 41 states and territories with such laws on the books. Another win: a step therapy bill in New Mexico.Currently, 42 state and local rheumatology societies are members of the ASC.
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Pushing Back on PBMs
One major push for 2018 has been to limit the reach of pharmacy benefit managers (PBMs) by mandating transparency and addressing gag orders that prevent pharmacists from telling consumers when the cash price of the drug is cheaper than the insurance company’s clandestinely negotiated price. Nationwide, the ASC saw approximately 30 bills introduced to address PBMs. The strongest one, according to Mr. Cantrell, was passage of a law in Arkansas that brings PBMs under the regulatory authority of that state’s insurance commissioner.
The ASC is tracking another 50 bills this year. Because we are in an election year, Mr. Cantrell says, “It has been a relatively slower year from a legislative aspect.” But, he continues, “we still have about a 20% success rate on the bills that we support or oppose—much higher than the standard 3% rate of introduced bills becoming law.”
Ingredients for Successful Advocacy
As sessions adjourn, the ASC and state societies continue their work, strengthening networks and making the case for new legislation in 2019. The ongoing process, says Christopher Adams, MD, a rheumatologist with the East Alabama Rheumatology Center, managed care liaison for the Alabama Society of Rheumatic Diseases and chair of the ASC, entails taking the long view. Dr. Adams has been active in state governmental affairs for more than a decade and has learned from experience that victories don’t happen overnight.
He says it’s best to approach insurers and legislators from a collaborative standpoint: “You have to look for aligned incentives, because if you go in with an antagonistic perspective, you’re going to lose,” he says. His hospital, East Alabama Medical Center, hosts a legislative update event every year, inviting state representatives. This has afforded physicians the opportunity to approach legislators and offer their expertise as a resource.
Another key ingredient to successful advocacy, Dr. Adams says, is fostering empathy. He explains, “My staff and I are empathetic toward patients, because we are dealing with them directly. But administrators are one or two steps removed.” Insurance company executives and policymakers are even more distant, so it may be more difficult for them to appreciate the real-life consequences of prior authorizations, step therapy or fail-first policies on patients’ everyday lives. Establishing those connections with policymakers, often through patient and first-person stories, can bridge the empathic gap and lead to incentives for policy change.
Getting in the Game
Looking forward, the ASC will continue a push on PBM transparency. Dr. Adams reports that the ASC is discussing the formation of ad hoc workgroups to focus on specific issues instead of grouping state societies based on their region.
Both asserted the need for more rheumatologists to engage with their elective representatives. Mr. Cantrell notes that he has encountered reticence from some rheumatologists who are concerned that advocacy might endanger their state society’s nonprofit status. He notes that advocacy expenditures are allowable within the IRS guidelines and encourages all state societies to become more informed on what is and is not allowed. Dr. Adams notes that it’s also advantageous to connect with one’s state medical society to cooperate on legislative advocacy.
“There is strength in numbers,” he states, “and rheumatologists can find allies among oncologists, gastroenterologists, dermatologists and other medical specialists.”
Gretchen Henkel is an award-winning health and medical journalist based in California.