As state legislatures begin to convene their sessions in 2025, several key issues related to rheumatology are expected to take center stage. These legislative priorities could significantly impact patients, providers and the cost of care for those managing chronic rheumatic diseases. As we look toward the future, here is an overview of the key issues likely to shape the state legislative landscape for rheumatology in 2025.
Prescription Drug Transparency & Affordability
The high cost of prescription drugs will remain a significant concern for legislators and policymakers. In the absence of Congressional action, states will continue to look for ways to lower drug costs. We expect to see legislation focusing on price transparency measures aimed at pharmacy benefit managers (PBMs), manufacturers and insurers. In the near term, we expect PBMs to remain one the favorite targets of policymakers, but we have seen an increasing focus on other areas of the pharmaceutical supply chain as well. That trend will likely continue, especially in the longer term.
There will also be renewed efforts to create prescription drug affordability review boards (PDABs) that can set upper price limits (UPL) for drugs deemed “unaffordable.” These boards, though well intentioned, can have unintended downstream negative consequences on patient access and physician reimbursement. Four states are already considering PDABs in 2025. Thus far, the PDABs that have been established have worked very slowly. None have successfully implemented UPLs. We will continue to monitor PDAB implementation to determine if the potential negative impacts are real or theoretical, but the ACR will continue to urge policymakers to use caution when considering PDAB legislation.
Utilization Management Reform
One of the most pressing concerns in rheumatology remains the administrative burden of utilization management requirements. Many state legislatures will be considering bills to reform prior authorization and step therapy processes, ensuring patients receive timely access to essential medications and treatments. Proposals include:
- Mandating shorter prior authorization and step therapy response times from insurers;
- Implementing gold card programs that waive prior authorization requirements for providers with high prior authorization approval rates;
- Enhancing transparency by requiring insurers to publish data on prior authorization and step therapy denials and appeals; and
- Requiring exemptions for step therapy protocols, such as when a patient has tried and failed to respond to a drug or the patient is stable on a medication.
The role of artificial intelligence (AI) in utilization management is likely to become an increasing focus of policymakers. For providers, AI is a double-edged sword: it has the potential either to increase administrative burden and make practice more difficult or to greatly decrease administrative burden by creating more streamlined and automated utilization management processes. The role of AI in practice is evolving quickly, and policymakers will inevitably be playing catchup. We will continue to work to ensure that AI policy is structured so that it works better for our members and their patients than for payers.
