When these proposals on drug pricing were introduced, it was immediately clear that our advocacy and education of policymakers would again be critical. We share the administration’s and HHS’s goal to provide patients with high-quality, cost-effective treatment, but we need to remain vigilant and engaged so proposals to reduce patient costs do not weaken or inhibit access to care and our ability to prescribe the right therapy for a patient.
With an issue as complex as drug pricing, it is much more likely that efforts to create a universal a solution will miss the mark for some specialties and patients. This was abundantly clear as we began reviewing proposals and comments by administration officials. For example, it appears policymakers are focusing on incentivizing use of lower-cost therapy options, even if it is through policies that penalize use of high-cost therapies.
This is concerning for the rheumatology community because providers don’t have equally effective, less expensive alternative therapies to choose from. Generally, when a rheumatologist reaches for a biologic therapy, the patient has already failed a less expensive therapy, and we know the biologic therapies our patients rely on to control their disease can be life changing. We and our patients have a narrow range of treatment options, and the costs associated with these treatments do not vary widely, but many policymakers may not be aware of this fact. We must educate policymakers as part of our advocacy efforts.
There also appears to be a lack of understanding of the nature of the barriers our patients face when it comes to the utilization management techniques used by PBMs and payers in the commercial and Medicare Part D spaces. Step therapy, or fail-first requirements, in Part D and commercial plans are among the practices that delay patients getting the right treatment when they need it. When a patient is granted access to a requested therapy, the out-of-pocket costs for patients are often very high or literally unaffordable for RA patients.
Yet these barriers are overlooked in proposals to move the therapies currently in Part B—where these hurdles are not usually an issue—into the Part D structure, in which patients currently experience significant access to treatment challenges. The proposal may seem to make sense to policymakers who believe PBMs and others can manage these drugs and formularies in a way that produces cost savings. It may not be obvious to them that patient access to the treatments they need may be jeopardized if this happens and the challenges with Part D are not addressed. It is paramount that the quest for savings does not take priority over patient access and standard of care in rheumatology practice. How will policymakers know about this nuance if we don’t get involved?
Call to Action
I want to personally thank all ACR and ARHP members who take the time to reach out to lawmakers, as well as those who stay engaged with the ACR/ARHP by volunteer involvement or by letting us know the challenges you face in your practice. Hearing from you allows us to better identify and frame the issues for policymakers. You can contact your lawmakers through our Legislative Action Center—writing them on a number of important preselected issues with suggested messaging or simply using the portal to send your own individual concerns—and you can contact your advocacy team at [email protected] with policy concerns or help building on your own advocacy efforts.
