The ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care has been busy as usual, and I’d like to provide an update on some of our active issues. These include recent activities regarding specialty pharmacy drug acquisition, consultation codes, modifier -25 policies and UnitedHealthcare’s (UHC) policy to move in-office treatments to self-administration.
Specialty Drug Acquisition
In November 2019, Blue Cross of Tennessee announced a policy in which many of its self-insured plans would require patients receiving in-office treatments to receive their drugs through a specialty pharmacy rather than allowing providers to “buy and bill.” As you might imagine, this policy has generated extensive pushback from the ACR, the Tennessee Rheumatology Society (TRS) and many other specialists (including dermatologists, gastroenterologists, ophthalmologists and urologists) within the state. Due to the degree of pushback, the policy is currently on a six-month delay, during which time we are working closely with the TRS, specialty societies and other rheumatology groups, such as the Coalition of State Rheumatology Societies (CSRO).
Our current advocacy plan includes appeals directly to the payer in Tennessee and, in collaboration with CSRO, preparing a press release and informational handouts for patients and employers in Tennessee and elsewhere. These outreach materials explain why many providers cannot accept specialty pharmacy drugs for in-office administration. The reasons include logistical challenges related to drug tracking, just-in-time delivery and dose adjustments, as well as financial burdens related to higher administrative costs and loss of drug margin to pay such costs.
Coincident to this policy in Tennessee, we are seeing the same issue pop up with certain employer groups with other payers, such as UHC in the St. Louis, Mo., area. Broadly speaking, we are concerned we may see more and more such policies as payers or pharmacy benefit managers (PBMs) try to sell employers on plans they market as “cost saving” through this specialty pharmacy mandate. We see the payers stating “the employers are asking for this,” but we believe most employers purchasing such plans are unaware of how they may limit access to care and hurt their employees.
Recent data from Medicare suggest the buy-and-bill system provides more effective cost containment of specialty drugs, with a 21% vs 45% increase in drug prices in parts B and D, respectively, from 2012–16.1 We see a strong argument that pushing drugs through the PBM system creates upward price pressure because a higher list price translates to a higher rebate, which is often not passed on to the employer or patient. By contrast, buy and bill creates downward price pressure by allowing providers to acquire a drug at the lowest possible price, which becomes reflected in average sales price several quarters later.
