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.
Copay Accumulator & Maximizer Programs
Many rheumatology patients rely on manufacturer copay assistance to afford expensive treatments. However, copay accumulator and maximizer programs implemented by insurers and PBMs prevent these funds from counting toward patients’ deductibles or out-of-pocket maximums.
Once again, many states will be considering bills to regulate these practices, ensuring that copay assistance benefits patients directly. We expect bills to be reintroduced in all the states where they failed last year, plus a few more. Progress on this issue has been slower than we hoped but steady, and we remain optimistic about the possibilities for copay accumulator legislation in 2025.
Telehealth Initiatives
Since the pandemic, telehealth has become a fixture in many rheumatology practices. Although most people think of telehealth in terms of treating basic illnesses, telehealth has become a deeply valued flexibility for rheumatology patients and providers. In the coming year, we will continue to support telehealth reimbursement parity to give providers and patients the flexibility they need. This is especially important for patients in rural and underserved areas.
Telehealth has also proven important for patients and providers who live in areas where natural disasters are occurring or have recently occurred. Telehealth enables rheumatology patients to have undisrupted access to their provider even in the aftermath of hurricanes or wildfires. It has truly become an indispensable tool for rheumatology care, and the ACR is committed to preserving telehealth flexibility and reimbursement for the long term.
Your Engagement Is Imperative
The ACR will be weighing in on all these issues and more, but it is imperative that you speak out as well. As a rheumatology provider, you have a powerful voice to advocate for your patients and your profession. By engaging in advocacy, you can help shape policies to eliminate barriers to care, such as prior authorization delays, restrictive step-therapy protocols and inadequate insurance coverage for life-changing treatments.
Your expertise is invaluable to policymakers, who rely on informed perspectives to make decisions affecting healthcare. Advocacy doesn’t require extensive time or effort—writing letters, meeting with legislators and supporting RheumPAC can all make a profound impact.
Together, we can create a healthcare system that prioritizes the needs of patients with rheumatic diseases and empowers providers to deliver the best possible care. Your involvement matters now more than ever.
Joseph Cantrell, JD, is the director of state affairs and community relations for the ACR.