Greetings, advocates! This month’s Washington update covers how Congress’s tax proposals affect rheumatology, the ACR’s plan to fight Medicare’s adjustments to Part B drug costs in MIPS, the good news of Medicare’s new individualized biosimilar reimbursement, advances in the rheumatology-specific Alternative Payment Model and developments in Congress’s awareness about the perilous pharmacy benefit manager system.
Senator Addresses ACR
In case you missed it: Sen. Lisa Murkowski (R-Alaska) spoke by video at the 2017 ACR/ARHP Annual Meeting in San Diego about her efforts in Congress to create patient-friendly health reforms. Check out her three-minute talk. The ACR awarded Sen. Murkowski the 2017 Award for Public Leadership in Rheumatology for championing causes critical to the rheumatology community.
Tax Reform Bills
On Nov. 16, the U.S. House of Representatives passed tax legislation repealing waivers that allow grad students to avoid paying tax on tuition assistance grants, which makes higher education tuition grants taxable. This would reduce incentives to go into biomedical research fields and could greatly limit rheumatology research.
Meanwhile, the Senate tax bill keeps those waivers, fortunately, but proposes repealing the Affordable Care Act’s (ACA) individual mandate to buy insurance. The Congressional Budget Office (CBO) estimates that such a move on its own could cause 13 million people to lose insurance. The ACR released a statement urging Congress to protect the tax waivers for graduate student tuition and to support continuous health insurance coverage.
Finally, and of dire concern to us, the CBO also estimated that these tax reforms may increase the deficit, triggering further sequester cuts—up to 4% more in Medicare payments. The ACR is actively monitoring this fast-moving development.
The Part B Perfect Storm
Challenging news: On Nov. 2, the Centers for Medicare and Medicaid Services (CMS) finalized a plan to adjust Part B drug costs in the MIPS program starting in 2020 based on 2018 performance. This means providers of our expensive drugs may be at risk of reimbursement cuts that could be as high as 5% of those high drug costs—and that percentage will grow to 9% over three years. This could potentially bankrupt a practice that passes through those drug costs with a 4% margin and would therefore severely limit patients’ access to treatment.
The ACR advocacy team has already voiced our strong opposition to the Congressional committees responsible for fixing the problem of MIPS adjusting Part B drug costs, and we are now working with coalition partners (oncology, ophthalmology, gastroenterology, urology, other physician specialties, and patient groups) to leverage our message. We’ll soon have information available in the Legislative Action Center on how you can get involved.
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.
Biosimilars
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.
Meanwhile, the ACR and ATAP will be asking the federal government for clear definitions of the rebates and fees that PBMs use in their business practices as a first step toward forcing transparency and, ultimately, reforming the system.
Finally, I’ve got to give a shout out to Mattie Feldman, MD, the national leader on PBM reform, seen in this photo giving her outstanding lecture on PBMs to ACR Advocates for Arthritis in September.
Thanks to those who have read this far—and if you did, you understand the high-stakes challenges and opportunities your advocacy team and all of us are facing. No doubt you’re fired up to get involved, and that’s great because we need all of us working to protect the rheumatology subspecialty and our patients’ access to care and treatment. Your personal involvement is needed and appreciated.
A happy Thanksgiving to all!
Angus Worthing, MD, FACP, FACR, chair, Government Affairs Committee, is a practicing rheumatologist in the Washington, D.C., metro area and clinical assistant professor of medicine at Georgetown University.
