The American College of Rheumatology (ACR) Board of Directors is assisted in advocating for appropriate coverage and payment policies by many hardworking volunteers, particularly the members of the Insurance Subcommittee (ISC). This group represents the ACR and its membership to the insurance industry and strives to position the ACR as a valuable resource to payers—as the experts for treatment guidelines, as advocates for patients and providers and as good stewards of the greater health system. I appreciate and applaud the work the ISC has done to Advance Rheumatology!, and I look forward to working closely with these members in the coming year (see sidebar, below).
Update on Current Issues
Ensuring Medicare beneficiaries’ access to critical, lifesaving biologic treatments remains a top priority for the ACR. Although most Medicare contractors recognize these drugs as highly complex, several have said they will only cover the infusion of biologic agents at the lower reimbursement level of a therapeutic injection. Misclassifying or down coding the administration of these drugs means fewer practices will be able to provide these services to their Medicare patients. The ACR feels strongly that Medicare patients in certain regions should not be treated differently than patients in the rest of the U.S. and should not be deprived of valuable therapies that are controlling their conditions. In response to the reduction of payment for these services, we recently reached out to all of the carrier medical directors and will be following up with conference calls on this issue early this year.
We continue to be vigilant regarding access issues with private carriers. This past summer, we were informed that United Healthcare (UHC) was considering a formulary change that would force stable patients to switch medications. After several rounds of discussions, we were pleased to hear that UHC decided to grandfather all new and existing patients on their current medication. We remain deeply dismayed, however, by their decision to move forward with limiting the use of co-pay assistance programs. Preventing patients on non-preferred therapies from using these programs will severely limit access to critical treatments and jeopardize patients’ well-being. The ACR continues to fight this policy change.
Another access issue we’ve engaged with insurers over is low, maximum-dosage policies. It was brought to our attention this past year that several carriers were limiting doses of infliximab to levels significantly below the FDA-recommended guidelines on the package insert. These carriers also sought to recoup on infliximab infusions dating to mid-2014. The ACR reached out to carriers to discuss this problem and advocate for increasing the caps in accordance with standard of care. We were pleased, when in late October, both Aetna and Humana retroactively increased the maximum allowable dose. We continue to monitor this issue and will engage in follow-up with carriers as necessary.
