Members play a key role in helping the ACR learn about insurance challenges or harmful policies that hurt patients—often, the ACR first hears about such problems from members. To help out, the College has a dedicated team of insurance advocacy experts who communicate directly with payers when they learn that a practice is having difficulty with a third-party payer.
Take the College’s recent success with shifting the tide on underwater biosimilars. Members like Donald Thomas, MD, FACP, FACR, RhMSUS, CCD, a rheumatologist with Arthritis and Pain Associates of PG County in Greenbelt, Md., sought advice from the ACR earlier this year after insurance companies started requiring certain biosimilar intravenous biologics that they were reimbursing at rates below the drug purchase price.
The ACR took action. “After investigating, we quickly learned that pricing strategies aimed at getting biosimilars a favorable formulary placement had the unfortunate side effect of lowering these drugs’ average sales price below acquisition cost,” says ACR Practice Advocacy Director Meredith Strozier.
She collaborated with Rebecca Shepherd, MD, MBA, FACP, FACR, chair of the ACR Committee for Rheumatologic Care (CORC)’s Insurance Subcommittee (ISC). The ISC moved swiftly to educate commercial payers on this problem and how it was “leaving practices unable to provide these critical therapies to patients,” notes Dr. Shepherd.
Since then, Aetna, UnitedHealthcare, Cigna, Blue Cross NC and CareFirst have made temporary changes to their fee schedules to help ensure practices are reimbursed enough to continue providing these drugs.
“After I informed Meredith’s team, the insurance companies responded by appropriately reimbursing the medications so that our patients can continue to receive treatment,” Dr. Thomas notes.
This favorable shift in reimbursement for biosimilars is a perfect example of how members sharing their insurance questions or problems with the ACR can help us understand where to direct our efforts with payers, Dr. Shepherd stresses. And this advocacy work is ongoing, she says. “A large push by the ACR is underway for broad talks regarding a global fix for underwater biosimilars with many stakeholders as well as discussions with individual health insurers.”
Getting to Know Your ACR Insurance Advocacy Experts
Ms. Strozier is part of ACR’s practice team, a group of ACR staff with expertise on a range of rheumatology practice issues, spanning individual members’ specific coding or insurance concerns to broader policy issues impacting many rheumatologists and patients across the country. “Most often,” she notes, “if one practice has a new challenge pop up with a payer, other practices are likely facing it, too.”
