ACR Praises Congress for Bill with Part B Fix, Therapy Caps Repeal

The ACR praises Congressional leaders for passing the sweeping spending agreement, which includes a technical provision reversing a Centers for Medicare & Medicaid Services (CMS) policy that would have linked physicians’ quality payment adjustments to Medicare Part B drug costs starting in 2019. The ACR also applauds the inclusion of provisions that permanently repeal Medicare caps on outpatient therapies and other rehabilitation services, repeal the Independent Payment Advisory Board (IPAB) and eliminate the Medicare Part D donut hole.

“The healthcare provisions included in the spending agreement are a huge victory for the more than 54 million Americans living with rheumatic diseases, many of whom rely on biologic therapies and vital rehabilitation services to manage their disease,” said ACR President David Daikh, MD, PhD. “We thank Congressional leaders for coming together swiftly and in a bipartisan fashion to ensure that Americans living with diseases like rheumatoid arthritis can access the infusion therapies and rehabilitation services that help them avoid disability and maintain quality of life. This victory would not have been possible without the efforts of the many rheumatologists and rheumatology health professionals throughout the nation who voiced their concerns to lawmakers and brought attention to these incredibly important issues.”

The Part B technical correction in the spending bill comes after the ACR and more than 100 other healthcare groups urged Congressional leaders to step in and reverse course on a CMS policy that would have created extreme financial volatility for specialists who administer Part B drugs and would have made it more difficult for patients—particularly those living in rural and underserved areas of the country—to access physician-administered infusion therapies.

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According to an analysis from Avalere Health, certain specialists who administer Part B drugs—including rheumatologists, oncologists and ophthalmologists—would have seen payment cuts as high as 29% under the CMS policy to factor Part B drugs in Merit-Based Incentive Payment System payment calculations, compromising the ability of some providers to continue administering complex infusion therapies in the office setting.

The current Part B drug payment structure already makes it difficult for providers—particularly small practices and those operating in rural areas—to shoulder the financial burden of procuring and administering Part B drugs. Infusion therapies covered by the Part B program are often expensive, with few or no generic alternatives, and providers have been subjected to repeated Part B reimbursement cuts over the past decade.

“The Part B technical fix is an important course correction that will hopefully lead to productive discussions about how to realistically address the issues of care access and high drug costs,” said Dr. Daikh.

In January, an arbitrary cap was placed on Medicare outpatient therapies and other rehabilitation services 20 years after being approved in the Balanced Budget Act. Congress temporarily prevented the implementation of the caps 16 times before it began limiting access to services on Jan. 1, 2018. A permanent repeal of these caps ends a long battle to allow Medicare patients access to the care they need based on individual circumstances.

Rheumatologists also celebrate the repeal of IPAB, the 15-member appointed board whose recommendations came with a statutorily mandated fast-track legislative procedure that would automatically transform IPAB proposals into law. Such recommendations had the power to impose provider cuts that could disproportionately impact small and rural practices. The ACR is relieved that such policies will undergo the detailed review and deliberation of the regular legislative process in the future.

Since 2006, eligible Medicare beneficiaries have had the option of purchasing a prescription drug benefit plan to cover medications. After meeting their deductible (which was a maximum of $400 for 2017), beneficiaries were responsible for only 25% of the original cost of prescription drugs on their plan’s formulary. However, until changes were made in 2011, patients whose prescription costs were more than $3,700 found themselves in a coverage gap, or donut hole, in which they would be responsible for the full cost of their drugs until they reached an out-of-pocket threshold, which was $4,950 in 2017. After reaching the threshold, patients paid only 5% of their drug costs. The closing of this gap allows patients to access necessary medications and supports the ACR’s goal of access to care and our patients’ ability to adhere to carefully determined treatment plans.

“We applaud Congress for acting to protect patient access to vital therapies and services, and we look forward to working with the Administration and Congressional leaders to ensure patients living with rheumatoid arthritis and other rheumatologic conditions continue to receive innovative, medically necessary and life-sustaining care,” concluded Dr. Daikh.