The Good Brigade / offset
On behalf of the ACR, I wish you happiness, prosperity and, above all, good health in this new decade.
Now that the holidays are behind us and 2020 has launched, the ACR’s dedicated volunteers and staff are working collaboratively to achieve many ambitious initiatives to ensure the College’s dynamic and bright future.
A few weeks ago in The Rheumatologist, I shared my thoughts about the ACR’s goals for the coming year and beyond. Ensuring access to effective and safe medications for our patients to control disease activity and restore and retain quality of life remains a pressing concern for rheumatologists and members of the interprofessional team. Although we see more medications than ever before being approved for the treatment of rheumatic diseases, our patients cannot benefit if these treatments are out of reach.
Some concerning coverage gaps and reimbursement challenges that affect our members and patients have arisen. In many states, we are seeing resistance from major payers not only to covering medications critical for our patients, but also to cover consulting services. What is the ACR doing to fight back on behalf of our patients?
The ACR Insurance Subcommittee (ISC), a branch of the Committee on Rheumatologic Care, has been working diligently with its staff to address urgent coverage and reimbursement issues that put the health of our patients and the fiscal viability of many rheumatology practices in jeopardy. The ISC is engaged in immediate, persistent advocacy to address these challenges with specific payers, and remains engaged with stakeholders on all sides of these issues.
Coverage for Physician-Administered Drugs
One ongoing issue that affects both rheumatology practices and our patients is coverage for many commonly prescribed, infusible, biologic drugs. Some payers have recently changed policies to require patients first fail self-administered formulations before providing coverage for infusible biologics. Despite advocacy efforts by the ISC against this change, many patients continue to face coverage delays.
At the ACR, we believe collaborative advocacy is a powerful tool. The ACR recently led a coalition of rheumatology organizations, including 25 state rheumatology societies, the Coalition of State Rheumatology Organizations (CRSO), the Arthritis Foundation, the Association of Women in Rheumatology (AWIR) and the National Organization of Rheumatology Managers (NORM), to advocate for a permanent cessation of a major insurer’s proposed fail-first policies. The ISC has also spoken directly to insurance companies and requested they provide advance notification to physicians before enacting any changes to coverage of these important therapies for our patients.
The ACR is staying fully engaged with payers about fail-first policies. We have agreed to assist one major insurer in developing a list of exceptions criteria that would help protect patients and support clinical decision making by ensuring patients can be excluded from the step requirements when necessary. We have also insisted that payers who enact fail-first policies grandfather coverage for any patients on existing therapy, so that they may continue with uninterrupted access to the medications they need to control their disease.
Forcing Providers to Obtain Drugs Through Designated Specialty Pharmacies
Another current concern is that individual insurance companies may require drugs for in-office administration be purchased through a preferred specialty pharmacy network. This change undermines the buy-and-bill system, threatens our patients’ access to desperately needed treatments and increases the already burdensome level of administrative work rheumatology practices face. Rheumatology practices that engage in buy-and-bill operate under razor-thin financial margins. If they have no choice but to obtain drugs from a specialty pharmacy, these margins could evaporate.
The ACR will immediately engage with any payers that implement this change to advocate against it. We will continue to stress the burdens, both financial and administrative, many rheumatology practices face because of these new constraints and our belief that patients deserve access to their medications at the best possible price.
Elimination of Consultation Codes & Payment for E/M Codes
Another concerning trend we have seen among payers is discontinuation of reimbursement for consultation codes. Several regional and national payers have already stopped paying for these codes, following the example set by the Centers for Medicare & Medicaid Service (CMS) when it eliminated these codes in 2010.
Persistent engagement by the ACR to educate decision makers at the CMS and payers on the value of cognitive care services has yielded some positive results, however. Recently, the CMS acknowledged that cognitive care was undervalued, and the now-finalized 2021 Physician Fee Schedule rule includes an estimated 15% increase in payment for evaluation and management codes for rheumatologists—an important and welcome change for our members. The ISC is using this victory to encourage commercial payers to make similar changes. In addition, after engaging with the ISC, one payer that had recently eliminated consultation codes has agreed to follow the CMS’s lead by increasing reimbursement for cognitive care services.
The ACR has a strong leadership role to play in advocating for fair valuation of cognitive care. When our members speak out on these issues with firsthand knowledge of the impact and complexity of the services we provide to our patients, policy makers listen and better understand our positions. The ACR remains committed to advocacy in this area throughout this upcoming election year and in the years to come, no matter the result of the next election.
How You Can Help
When faced with troubling situations, members are encouraged to immediately contact the ISC at [email protected]. Both ACR staff and subcommittee members can intervene on behalf of rheumatologists to address these issues and achieve favorable results. Members are also encouraged to provide examples to the ACR of the real-world impact of insurance policies on practices and patients to assist the ACR in our efforts to educate payers and policy makers.
Follow the ISC’s important current advocacy efforts and priorities by visiting www.ACRInsuranceAdvocacy.org, where you will also find templates for letters to payers and complaint forms to health plans for specific issues that may arise in your practice. ACR/ARP members may also stay abreast of current legislation and payer policies that affect access to medications, affordability of medications and reimbursement by reading our e-newsletter, ACR@Work.
I hope you share my pride in the incredibly valuable, impactful work of the ISC and its staff. With their advocacy efforts and their vigilance, the ACR hopes to achieve its ultimate goal of ensuring that every patient receives the right medication at the right time at a price they can afford, and that rheumatology practices not only survive, but thrive and can continue to offer the very best care to every patient in every community.
Ellen M. Gravallese, MD, is chief of the Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital, Harvard Medical School, Boston. She is the 83rd president of the ACR.
