Meanwhile, a perfect storm is brewing related to costs: MIPS will also begin weighing costs at 10% in 2019 performance scores. Also, because the CMS has not yet been able to identify a methodology for Part D drug costs to be counted, Part B providers may be unfairly given worse cost scores. Stay tuned.
Lots of good news here: On Nov. 2, the CMS changed its earlier established policy on reimbursement of biosimilars administered in the doctor’s office. Instead of reimbursement based on the average price of all biosimilars that refer to one bio-originator (Inflectra and Remsima, for example), the CMS will instead reimburse for each drug based on its own individual billing code. Thus, reimbursement will reflect costs more accurately and fairly.
That same day, the CMS changed its cost-sharing policy for patients who will be using self-administered biosimilars under Part D, so that biosimilars won’t be more expensive for patients. The ACR advocated strongly for both of these reforms, and they are both victories for the rheumatology community that will allow for a more seamless transition to safe and effective biosimilars.
Finally, the ACR’s white paper on biosimilars will be coming soon to an ACR journal in your inbox or mailbox. It’s chock full of helpful scientific and clinical information.
Alternative Payment Model (APM) for Rheumatology
At the ACR/ARHP Annual Meeting, Kwas Huston, MD, unveiled a near-final draft of the new APM for rheumatoid arthritis (RA). If approved by the CMS, it could allow rheumatologists to avoid MIPS cuts and instead receive monthly fees for taking care of people with RA, while adding valuable services and reducing costs using a guideline-driven treatment pathway.
Days later, our own Colin Edgerton, MD, chair of the Committee on Rheumatologic Care, testified at a Congressional hearing on APMs about the APM development experience. He asked Congress to reduce thresholds necessary to qualify for the APM track, and lower the financial risk required in APMs. Check out the video (Dr. Edgerton’s testimony begins at 2:35). The ACR has also asked the CMS for those changes.
Meanwhile, the CMS made it a bit easier to qualify in the APM track by proposing to allow Medicare Advantage participation to count as APM participation for groups to avoid MIPS.
Pharmacy Benefit Managers (PBMs)
Yes, PBMs. If you haven’t heard of them by now, read the FAQs on the Alliance for Transparent & Affordable Prescriptions (ATAP) website or “Understanding the Hidden Villain of Big Pharma: Pharmacy Benefit Managers.” There’s good news on this front as well: We may soon see more transparency in this opaque drug-pricing process. Medicare just proposed including more transparency for PBMs in Part D. Also, an October Senate hearing (the second of three hearings on drug prices) saw rigorous questioning from both sides of the aisle about the rebate system. President Trump’s pick to lead the Department of Health and Human Services (HHS), Alex Azar, has publicly blamed PBMs for high drug prices and advocated for changing the U.S. drug distribution system.