When insurance company practices put patients at risk, advocacy is an important tool physicians can use to make a real difference. The ACR and its members are actively advocating for rheumatologists and patients on priority issues, including prior authorization, step therapy, drug pricing and out-of-pocket costs. By speaking up and engaging their patients, rheumatologists can help change harmful practices.
Effects on Patient Care
Insurance company policies can negatively affect patient outcomes by delaying or altering treatment plans. Norman Gaylis, MD, the board liaison to the ACR Government Affairs Committee (GAC), sees delays in patient care at his Florida practice due to insurance requirements for prior authorization. The problem is especially pronounced early in the year, he says, because patients who change insurance plans must wait for new authorizations. In late January, numerous patients in his clinic were still waiting for treatment because their insurance companies had yet to provide authorization.
The increasing prevalence of step therapy policies is another area of concern, says Chris Phillips, MD, chair of the ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care. “Many of the step therapy requirements are not evidence based and oblige our members to abandon a planned treatment sequence based on clinical evidence and the provider’s experience,” he says. “And we know that opaque rebates between manufacturers and pharmacy benefit managers [PBMs] drive the tiering of drugs in these protocols.”
Step therapy policies can also lead to higher drug prices for patients. A medication required by an insurance company may be more expensive than an alternative recommended by the physician. In such cases, the patient ends up having to pay more to receive a non-recommended treatment.
High out-of-pocket expenses are another issue for patients. At Dr. Gaylis’s practice, some patients with new out-of-pocket requirements as of 2020 are finding their biologic therapies aren’t covered, he says. Practice staff try to help patients obtain free or reduced-cost treatments through foundations that support the cost of biological prescriptions. Without such assistance, however, patients may not be able to afford treatment.
The Importance of Advocacy
Effecting real change related to current priority issues is not easy, but it is possible through advocacy efforts. And there is strength in numbers, so the more people who get involved and speak up, the better the chances of success.
“The first step in advocacy is simply recognizing that it works,” Dr. Phillips says. “Only through our collective outreach—individually, as a group within rheumatology, and in the broader house of medicine—do things get done.”
Brian Loggins, practice manager, Arthritis Associates, San Antonio, Texas, and a member of the GAC, has gone to Washington, D.C., to advocate on the Hill several times. Being active in state politics is another way to be effective because federal policies often end up mirroring state policies, Mr. Loggins says. The Texas Medical Association, for example, recently helped get legislation introduced in the state to limit prior authorization requirements.
Empowering patients to get involved is another way to help drive positive change. In Tennessee, Dr. Phillips and the ISC are working with rheumatology practices to educate patients about such issues as specialty pharmacy policies that threaten patient access to in-office treatments. Informed patients can contact their employers’ human resources staff and encourage them to opt out of harmful insurance policies.
In St. Louis, Mo., outreach to a local insurance carrier’s representative resulted in the carrier reversing policies that required care at a hospital site, according to Dr. Phillips. The success resulted from informing the carrier’s representative about the advantages of in-office infusions for patients in terms of treatment and cost.
Restricting the availability of medications actually adds to the cost for both patients and physicians, according to Chris Morris, MD, FACR, a rheumatologist with Arthritis Associates, Kingsport, Tenn. ACR members in his state are working to address Blue Cross Blue Shield policies that prevent in-office treatments.
“The problem is there are certain areas, like where I live, where policies result in patients being unable to receive infusions in their physician’s office,” Dr. Morris says. “The patients either have to come off the medications or drive several hours to get the medicines we normally give in our office.”
How You Can Help
There are many ways ACR members can get involved in advocacy efforts, including writing letters to insurance carriers, working with the ACR and its committees, meeting with state legislators and disseminating information about insurance practices and medical needs. The GAC and ACR as a whole are dedicated to advocating for rheumatologists and their patients. In 2019 alone, there were several wins in the efforts related to step therapy, prior authorization and bone density scans, as recently reported by GAC chair Blair Solow, MD.
The ACR needs help fighting for changes in legislation, and the best weapon is a united front. Every rheumatologist and ACR member can advance rheumatology by advocating for rheumatology issues, practices and patients, at both state and federal levels. The ACR Advocacy Tools and Resources page provides information about how to get involved. For insurance-specific issues, the ISC exists to help combat harmful insurance practices. Another option is to invest in RheumPAC, the nonpartisan political action committee established by the ACR to help elect and support pro-rheumatology candidates.
“Advocacy is very important, and we have to keep doing it because there’s no one else doing it for us,” Dr. Gaylis says. “We need to get every rheumatologist involved.”
Kimberly J. Retzlaff is a freelance medical journalist based in Denver.