Unfortunately, we still have a long way to go because most of the time we are playing catch-up, reacting to policies that have been developed without any rheumatologic input. To stop this game, we need to continue our efforts to nurture our relationship with insurers and help them develop policies, while being mindful of our credibility. If our input is to say that rheumatologists know best and insurers should let us do whatever we want, we will lose. We must continue to focus on credible policies based on the best data available.
The ACR frequently learns about policies being enforced that require physicians to prescribe medications in a certain order. A recent example is Wellpoint requiring patients to try 30 days of prednisone and complete a Systemic Lupus Erythematosus Disease Activity Index prior to starting belimumab. In this case, the ACR heard about the issue from the ACR advocacy list serve. The Insurance Subcommittee took action on behalf of the ACR by writing a letter (PDF) and facilitating a conference call with Wellpoint. Wellpoint welcomed our input and agreed to review the matter when its Medical Policy and Technology Assessment Committee meets in May. Wellpoint also requested additional guidance from us. In response, the ACR is working with lupus experts to recommend the best measures to follow in the clinic.
In this case, the ACR worked alone; however, the ACR has also looked to other groups in addressing insurance issues. The ACR works with the Arthritis Foundation, American Academy of Pediatrics, and other relevant groups, as the situation warrants. For the past couple of years, the ACR and Arthritis Foundation have signed onto numerous letters, working closely together so insurance companies know that our concern is both from the physician and the patient perspective. The ACR also tries to align with other physician societies, such as the American Academy of Pediatrics, American Academy of Dermatology, and others.
Many of these conversations take place on the Specialty Society Insurance Coalition (SSIC) list serve run by the ACR. The SSIC comprises the major specialty societies and their insurance staff. The group has discussions about insurance issues via the list serve and holds conference calls and an annual in-person meetings. The ACR also works with the American Medical Association (AMA) and the AMA Federation on broader-scope issues such as communicating with insurance companies, prior authorizations, payment burdens, physician profiling, and others.
Through the Insurance Subcommittee, the ACR also sends out yearly mailings to insurance companies to inform them of issues affecting rheumatology and to request meetings. The mailing reminds the insurance companies that the ACR is monitoring what is happening and is there to help develop policies. One of our last mailings specifically requested in-person meetings to share information about the ACR and announced the release of the ACR Model Biologics Policy (PDF). This year, the mailing is emphasizing prior authorizations.
Prior Authorization vs. the Patient
You all know that prior authorizations are a major administrative burden, and more physicians are being asked to preauthorize medications that have a minimal cost. A recent example of preauthorization for folic acid comes to mind. The ACR is asking insurance companies to stop this behavior, which can be abusive, and allow patients to receive the treatments they need without jumping through hoops. The ACR is also working with the National Council for Prescription Drug Programs (NCPDP) to standardize prior authorizations and develop an electronic format. CVS Caremark is one of three members of a NCPDP Task Force to standardize electronic prior authorizations and is currently doing a pilot program with some states (including some rheumatology offices) before launching the program in the near future. In the meantime, the ACR will continue to encourage insurance companies and pharmacy benefit managers to standardize their prior authorization forms and allow information to be printed from electronic medical records to make the process less burdensome for physicians and patients.
Think of how much time and energy could be saved if insurance companies would stop or lessen these administrative burdens, and how much more fun it would be to practice.
The Self-Insured Market
I am aware that the self-insurance market covers as large a population as the one covered through large employers. Companies now work directly with insurance companies to define their own policies, making it increasingly difficult to figure out policies because large employers come up with their own “rules” on how they will deal with employees/patients. The ACR is taking a proactive approach, reaching out to the 100 largest self-insured companies. The companies will receive a letter and short brochure explaining the importance of patients getting the right treatment at the right time and reducing employees’ time away from work. In one recent survey of people with rheumatoid arthritis, researchers found that over a three-month period, employees with RA missed an average of two to three weeks of work.2 As rheumatologists, we know that patients want to work. We hope to continue collaborating with these companies and keeping them informed, especially as they develop their health care policies around the diseases we treat.
What You Can Do
So far, I have discussed in great detail what is happening with insurance, but I have not said much about what you can do. We need you, ACR members! The Insurance Subcommittee cannot work on issues unless you contact the practice management department and let them know the issue. You can call (404-633-3777), e-mail ([email protected]), or fill out a form online. The system works best if ACR staff can address the issue immediately before it spreads to other states or areas.
