The best interests of patients and physicians are often at loggerheads with the efforts by Medicare and private insurance companies to contain healthcare costs. To contain costs in rheumatology, Medicare carriers and insurers have focused much of their attention on the high price of specialty pharmaceuticals. The use of specialty drugs, such as those in the biologic class, has undeniably improved the outcomes of patients with complex, difficult-to-manage, chronic inflammatory diseases, such as rheumatoid arthritis. Although their high price has been rationalized by the need for sustained investment in biopharmaceutical research and drug development, it’s hard to ignore the personal stories from desperate patients who don’t have the financial means to access these costly therapies.
Medicare carriers and insurance companies attempt to manage their utilization by creating specialty tiers and complex formulary designs; imposing drug restrictions, dose limits and prior authorizations; and implementing co-pays and co-insurance that transfer some of the cost burden to the patient. In addition, insurers are now turning to specialty pharmacies, which can create cost savings through management of the complex reimbursement process and implementation of mechanisms to ensure physician adherence to clinical pathways. Specialty pharmacies also have access to discounted drug pricing, available to them as large-volume distributors. The use of these management services has raised concerns about fragmentation of care because they fall outside the usual clinical care setting. By directly distributing drugs to physicians’ offices, specialty pharmacies take the office-based practice out of the “buy and bill” process, create administrative hassles and drive patients toward the use of more costly hospital-based infusion centers.
It’s important that we protect the viability of our specialty by advocating for coverage and payment policies that protect our patients and our practices. The ACR believes that rheumatologists should be adequately reimbursed for the office visits and management of these complex therapies, which require toxicity monitoring, continued reassessment for possible side effects and treatment modification to maximize efficacy. In addition, rheumatologists need to be appropriately reimbursed for infusing specialty drugs in their offices, which ensures appropriate coordination of care and has the downstream benefit of lower infusion costs. Finally, rheumatologists and their staff should be reimbursed for the extra time spent to educate and manage patients receiving these complex therapies. If insurance coverage and payments are not structured appropriately, then they will increase administrative burdens, hamper clinical care and alter clinical decision making to the detriment of serving our patients.
