Updates from the ACR Insurance Subcommittee Chair

The Insurance Subcommittee (ISC) of the ACR Committee on Rheumatologic Care has been very active recently, advocating to payers on behalf of our colleagues and the College. I’d like to share an update about several of the issues this group has been working on.

Blue Cross NC Autoimmune Pathways Program

Dr. Shepherd

Blue Cross NC, in partnership with Outcomes Matter Innovations (OMI), introduced the Autoimmune Pathways Program with the stated goal of reducing spending on specialty drugs. The initial iteration of the program achieved these savings by paying physicians to delay the introduction of a biologic or to initiate tapering or so-called drug holidays for patients who are in remission or show low disease activity. The ACR shared significant concerns about the ethics of this program and potential harm to patients’ access to treatment. After conversations with the ACR, Blue Cross NC and OMI have committed to reworking some of the more controversial aspects of the program. The ACR will continue to monitor this evolving program and advocate for fair and transparent policies that protect patients’ access to biologic therapies.

Regence BlueShield LevelRx Program

Regence BlueShield, a payer operating in Idaho, Oregon, Utah and Washington, recently introduced the LevelRx program, creating a new specialty medication provider network to be administered by Prime Therapeutics. According to Regence, practices will still be able to directly source drugs for in-office administration; however, they will be required to sign a new contract covering reimbursement for both the drugs and administration. Practices that do not join the new network by Jan. 1, 2024, will be considered out of network with Regence BlueShield and required to obtain drugs through an approved specialty pharmacy.

The ACR sent a letter and spoke with Regence leadership, detailing our concerns about the increased administrative burden on practices and uncertainty around reimbursement rates moving forward. We are also working with local members and state societies to provide additional resources and coordinate ongoing advocacy efforts.

Aetna Coverage for Ultrasound

It was brought to the ISC’s attention that Aetna’s policy on ultrasound is overly restrictive, labeling ultrasound guidance to be “of no proven benefit” for numerous procedures that utilize musculoskeletal ultrasound (MSUS). The ACR sent a letter to Aetna outlining our concerns; we also joined a multispecialty sign-on letter that was led by the American Institute of Ultrasound in Medicine (AIUM). As a result of these letters and subsequent conversations with Aetna’s leadership, the payer has committed to considering the additional data during an internal policy review in October.

Need help with an insurance problem in your practice? The ISC exists to help members with issues related to insurance policies and payers. If you would like the ACR’s help regarding payer issues specific to your own practice or if there is a payer policy you think we should be aware of, reach out to [email protected].

Rebecca Shepherd, MD, MBA, FACR, FACP, is the chair of the Insurance Subcommittee of the ACR’s Committee on Rheumatologic Care. She is Chief of Rheumatology and Director of Osteoporosis Care at Lancaster General Health, Pa.