Step Therapy, Biosimilars among ACR’s 2017 State-Level Priorities

Opportunities and challenges will continue to face the rheumatology community in 2017. In response to these challenges, the ACR has outlined its federal– and state-level legislative and regulatory healthcare priorities for the year.

Howard Blumstein, MD, chair of the ACR Affiliate Society Council, says that achieving at least some of these priorities at the state level will mean continuing to strengthen state societies and physician representation in state capitols around the country.

“As we head into the next executive regime, it’s likely states will have more of a say, so I think it will be more important to have strong societies and rheumatologists willing to advocate for our patients,” Dr. Blumstein says.

4 Key Areas
Following extensive discussion, which culminates in the recommendation of a policy framework to the ACR Board of Directors, members of the ACR’s Government Affairs Committee (GAC) identified four key areas for state-level efforts this year:

1. Reducing the use and impact of step therapy formulary practices by all payers;
2. Streamlining prior authorization processes and forms;
3. Eliminating specialty drug cost tiering by all payers; and
4. Supporting a biosimilars marketplace that provides protection from inappropriate substitution practices and forced switching.

Step therapy
With respect to step therapy—in which insurers require patients to first try and fail one therapy before they can try another—Dr. Blumstein says the ACR would like to see “barriers removed” to reduce or eliminate “inappropriate” medication switching.

According to the National Psoriasis Foundation, a number of states have enacted or are considering legislation to address it. This includes New York, Dr. Blumstein says, where Gov. Cuomo signed step therapy legislation on Dec. 31, 2016.

“This culminates the efforts of numerous patient organizations, such as the Lupus and Allied Diseases Association, Lupus Foundation, Arthritis Foundation, and National Psoriasis Foundation, along with physician organizations like state rheumatology societies and the ACR,” says Dr. Blumstein. “This is the perfect example of the types of partnerships that are needed for success.”

Prior authorization
Prior authorization can be streamlined through a universal approach, Dr. Blumstein says, providing “a very clear pathway to approval for patients” that would be “less cumbersome” for staff.

Specialty tiers
Regarding specialty tiers, The Commonwealth Fund recently highlighted the fact that insurers have shifted the cost of drugs onto consumers as prices have risen.¹ Several states and the District of Columbia have acted to limit the burden on patients. New York has eliminated specialty tiers altogether. The ACR is working to support legislation in other states, says Angus Worthing, MD, FACR, FACP, chair of the ACR’s Government Affairs Committee (GAC).