The ACR Advocates for Drug Coverage, Payment Policies to Protect Rheumatology Patients, Practices

The best interests of patients and physicians are often at loggerheads with the efforts by Medicare and private insurance companies to contain healthcare costs. To contain costs in rheumatology, Medicare carriers and insurers have focused much of their attention on the high price of specialty pharmaceuticals. The use of specialty drugs, such as those in the biologic class, has undeniably improved the outcomes of patients with complex, difficult-to-manage, chronic inflammatory diseases, such as rheumatoid arthritis. Although their high price has been rationalized by the need for sustained investment in biopharmaceutical research and drug development, it’s hard to ignore the personal stories from desperate patients who don’t have the financial means to access these costly therapies.

Medicare carriers and insurance companies attempt to manage their utilization by creating specialty tiers and complex formulary designs; imposing drug restrictions, dose limits and prior authorizations; and implementing co-pays and co-insurance that transfer some of the cost burden to the patient. In addition, insurers are now turning to specialty pharmacies, which can create cost savings through management of the complex reimbursement process and implementation of mechanisms to ensure physician adherence to clinical pathways. Specialty pharmacies also have access to discounted drug pricing, available to them as large-volume distributors. The use of these management services has raised concerns about fragmentation of care because they fall outside the usual clinical care setting. By directly distributing drugs to physicians’ offices, specialty pharmacies take the office-based practice out of the “buy and bill” process, create administrative hassles and drive patients toward the use of more costly hospital-based infusion centers.

It’s important that we protect the viability of our specialty by advocating for coverage and payment policies that protect our patients and our practices. The ACR believes that rheumatologists should be adequately reimbursed for the office visits and management of these complex therapies, which require toxicity monitoring, continued reassessment for possible side effects and treatment modification to maximize efficacy. In addition, rheumatologists need to be appropriately reimbursed for infusing specialty drugs in their offices, which ensures appropriate coordination of care and has the downstream benefit of lower infusion costs. Finally, rheumatologists and their staff should be reimbursed for the extra time spent to educate and manage patients receiving these complex therapies. If insurance coverage and payments are not structured appropriately, then they will increase administrative burdens, hamper clinical care and alter clinical decision making to the detriment of serving our patients.

The American College of Rheumatology (ACR) Board of Directors is assisted in advocating for appropriate coverage and payment policies by many hardworking volunteers, particularly the members of the Insurance Subcommittee (ISC). This group represents the ACR and its membership to the insurance industry and strives to position the ACR as a valuable resource to payers—as the experts for treatment guidelines, as advocates for patients and providers and as good stewards of the greater health system. I appreciate and applaud the work the ISC has done to Advance Rheumatology!, and I look forward to working closely with these members in the coming year (see sidebar, below).

Update on Current Issues

Ensuring Medicare beneficiaries’ access to critical, lifesaving biologic treatments remains a top priority for the ACR. Although most Medicare contractors recognize these drugs as highly complex, several have said they will only cover the infusion of biologic agents at the lower reimbursement level of a therapeutic injection. Misclassifying or down coding the administration of these drugs means fewer practices will be able to provide these services to their Medicare patients. The ACR feels strongly that Medicare patients in certain regions should not be treated differently than patients in the rest of the U.S. and should not be deprived of valuable therapies that are controlling their conditions. In response to the reduction of payment for these services, we recently reached out to all of the carrier medical directors and will be following up with conference calls on this issue early this year.

We continue to be vigilant regarding access issues with private carriers. This past summer, we were informed that United Healthcare (UHC) was considering a formulary change that would force stable patients to switch medications. After several rounds of discussions, we were pleased to hear that UHC decided to grandfather all new and existing patients on their current medication. We remain deeply dismayed, however, by their decision to move forward with limiting the use of co-pay assistance programs. Preventing patients on non-preferred therapies from using these programs will severely limit access to critical treatments and jeopardize patients’ well-being. The ACR continues to fight this policy change.

Another access issue we’ve engaged with insurers over is low, maximum-dosage policies. It was brought to our attention this past year that several carriers were limiting doses of infliximab to levels significantly below the FDA-recommended guidelines on the package insert. These carriers also sought to recoup on infliximab infusions dating to mid-2014. The ACR reached out to carriers to discuss this problem and advocate for increasing the caps in accordance with standard of care. We were pleased, when in late October, both Aetna and Humana retroactively increased the maximum allowable dose. We continue to monitor this issue and will engage in follow-up with carriers as necessary.

In addition to our advocacy work with payers, the ACR has also provided feedback on draft policies and formulary changes. Since this past summer, we have reviewed and commented on seven draft policies for three different carriers. It allows us to serve as a trusted resource and gives us the opportunity to help shape policies with evidence-based research and guidelines.

Goals for the Year Ahead

As we begin 2015, I look forward to expanding our influence with both private carriers and Medicare contractors. The ISC will continue to dialogue with private carriers to safeguard the practice of rheumatology. As we build on these relationships, we will seek further opportunities to review policies and formularies, and provide input on standard of care. We will also continue to provide individualized support for emerging policy and reimbursement issues.

In addition to working with private carriers, we will look to bolster relations with Medicare contractors. One approach we will use is expanding our resources for educating and communicating with Carrier Advisory Committee members (CACs). These members are in a unique position to engage proactively with Medicare contractors. Improved communication with CACs will allow us to better represent the interests of rheumatology providers and our Medicare patients.

These efforts will go hand in hand with increased collaboration with the Affiliate Society Council (ASC). The Board of Directors has recently demonstrated its commitment to advocacy on both insurance and state-level priorities by creating new staff positions dedicated to each of these areas. Through increased coordination and by working closely with the CACs and ASC representatives, we will be able to quickly identify emerging issues and generate a strong and unified response.

Finally, we will seek additional opportunities to partner with other medical specialty societies and coalitions in our outreach to insurers. Working together will enable us to pool our resources and influence to better advocate for access to high-quality care.

A foundation of successful relationships with the insurance industry is critical and will serve us well as we pursue our mission to Advance Rheumatology! I look forward to building on this foundation in the coming year as we continue to confront the challenges of access to care and treatments for our patients.

E. William St.Clair, MD, is president of the ACR and chief of the Duke Division of Rheumatology and Immunology. Dr. St.Clair, a rheumatologist, has 25 years of experience as a clinical investigator. Contact him at [email protected].