Protect Your Patients’ Access to Care & Treatment

Persistent Challenges

Sometimes the challenges seem neverending. In addition to the rigors of our daily lives as rheumatology health professionals—growing administrative burdens, increasing pressures to fund research and achieve balance in family and personal lives—we face a growing number of challenges related to the rapidly escalating prices of rheumatology treatments. Even more unfortunately, these costs increasingly affect the lives of patients with a wide range of rheumatic disease.

To control cost, insurance carriers, pharmacy benefit managers and government lawmakers have long placed restrictions on the care and treatment we provide. For years, they’ve imposed requirements for prior authorizations, step therapy and specialty tiering to limit the utilization of medicines. Recently, rheumatologists and other specialists who commonly prescribe expensive treatments have faced a new challenge that threatens the financial viability of practicing medicine: a threatened, large cut in reimbursement for Part B drugs in Medicare. Just last year, the rheumatology community joined with patients and other physician groups to stop the cuts. This year, our community is facing a similar threat that, if implemented, could force many rheumatologists to stop prescribing the Part B drugs that are so important to our patients.

A Troubling Diversion

Late in 2017, when it finalized its rule for how the Quality Payment Program set up by MACRA would operate in 2018 and beyond, the CMS announced that it will begin applying Merit-Based Incentive Payment System (MIPS) payment adjustments to the reimbursements providers receive for Part B drug costs in 2019. This position is a drastic departure from previous policy in which reimbursement adjustments only affected payments for physician services provided under Part B. This new approach is particularly exasperating because rheumatologists and other physicians do not control the pass-through costs associated with the Part B drugs they provide to patients.

The high cost of these specialty drugs is a significant problem, and the ACR has consistently advocated for such rem­edies as allowing Medicare to use its negotiating power to lower the price of drugs. Unfortunately, payers continue to adopt con­voluted and increasingly indirect policies that frequently have disproportionate impact on small practices and unintended con­sequences for the cost and access for care for patients. In the instance of this policy, according to a troubling analysis from Avalere Health, some specialists could see payment cuts as high as 29% by 2020 if Part B drug costs are included in quality-program payment adjustments.

The prospect of such a dramatic payment swing could force those who provide in-office treatments into the impossible position of deciding whether to stop providing critical treatments to patients or alter treatment plans for patients who are currently stable—putting the patient’s health and safety at risk—or jeopardize the operational viability of their practice. We see it as an extreme disincentive for rheumatologists, particularly those in small practices and in rural settings, to provide Part B drugs in the office. This situation has the potential to create a dire patient access situation, because when patients cannot receive their treatment in their doctor’s office, they may not have other choices available, or the alternatives may require long drives or higher costs. Patients are already facing access challenges, because the budget sequester has eroded reimbursements to physicians and this policy would exacerbate these problems.

The ACR Takes Action

When the CMS proposed this new policy to adjust payment based on Part B drug costs, the ACR began a multipronged advocacy campaign. I and other members of the ACR Executive Committee met with Senate and House committee staff, the ACR met with Medicare leaders and sent official comment letters, and after you, our members, sent hundreds of letters to Congress, bipartisan groups of lawmakers from both chambers sent letters to CMS urging them to change the proposal. We also authored and successfully passed a resolution at the AMA House of Delegates that ensures the AMA will advocate against such policies, and we had several other physician specialties and state medical societies sign on to join our effort.