Range of Insurance Issues Challenge Rheumatology

The ACR is working with the AMA to ask for more guardrails to be put in place, such as the provider being able to define failure of treatment, exceptions if a medication is contraindicated or likely to be ineffective or cause harm, and exceptions for patients whose lives or physical function could be irreparably harmed by a delay in appropriate treatment, Dr. Phillips said.

Prior authorizations: The ACR has worked to ease the burden of prior authorization policies, “which can delay or deny care,” Dr. Bryant said.

Gary Bryant, MD

United has limited prior authorization requirements for certain procedures and radiologic treatments, but reserves the right to review after the fact, which “may be worse,” Dr. Bryant said. “If you provide the service and then they deny it on the back end, that’s going to take appeal time and that’s even more burden,” he said. “And so these are things you need to be aware of about what the prior authorization policies are.”

Biologic therapy: The U.S. Food & Drug Administration recently issued guidance on the interchangeability of biologics, and no biosimilars are currently considered interchangeable to the bio-originator product, Dr. Phillips said.

But several payers and even local hospitals have insisted on force switching patients who are stable on the bio-originator to biosimilars for infliximab, he said. One carrier is even requiring biosimilars for rituximab for all new medication starts, including rheumatic conditions, even though rituximab is only approved for oncologic conditions.

“Our position essentially is that unless these drugs are proven to be interchangeable, the decision to switch should belong to the patient and to the provider,” Dr. Phillips said.

Infusion sites: Anthem Blue Cross has shown data suggesting a 40% cost savings on infusions if they’re moved out of the hospital outpatient setting, so that is a big incentive to move patients to other infusion locations, Dr. Bryant said. And other payers have placed hospital outpatient infusions under close scrutiny.

“We’ve worked with, I believe, one payer this year who wanted to insist on home infusion of rituximab, which we thought was interesting,” he said, although that request was later dropped.

The ACR advocates for safe and timely access to the right treatment and urges the “recognition and mitigation of barriers related to travel for patients with arthritis and other rheumatic conditions.” The ACR also has not endorsed home infusions for complex biologics.