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Rheumatology Leaders Urge Congress to Tackle Prior Authorization Reform, PBM Transparency During Annual “Advocates for Arthritis” Event

Approximately 87 percent of physicians report that prior authorization has a significant or somewhat negative impact on patients’ clinical outcomes.

Nearly half of rheumatology patients reported difficulty affording prescription drugs in 2020

WASHINGTON, DC ­– More than 90 advocates from the rheumatology community ­– including patients, rheumatologists, and rheumatology interprofessional team members – are convening online this week for the American College of Rheumatology’s annual “Advocates for Arthritis” event.

In dozens of virtual meetings with Congressional members and their staff, rheumatology leaders are urging lawmakers to pass legislation that would improve care access and lower drug costs for the 54 million Americans living with a rheumatic disease.

“I am consistently inspired by our rheumatology advocates – both patients and providers – who work tirelessly throughout the year to make their voices heard and fight for accessible, affordable health care,” said Blair Solow, MD, Chair of the ACR’s Government Affairs Committee. “As Congress moves to wrap up this year’s appropriations and reconciliation bills, our message this week is an urgent one: Lawmakers must prioritize policies that will lower prescription drug costs and reduce prior authorization burdens for our patients.”

In video conferences with Congressional members and staff, ACR advocates are sharing their stories and urging lawmakers to support the following legislation:

  • The Improving Seniors’ Timely Access to Care Act (H.R. 3173) is bipartisan legislation introduced in the U.S. House earlier this year that would require the Centers for Medicare and Medicaid Services (CMS) to streamline the use of prior authorization by Medicare Advantage plans and establish a process to make 'real-time decisions' for services that are routinely approved. Plans would also be required to offer a process for electronic prior authorization and to report to CMS how extensively they use prior authorization and how often they approve or deny the relevant medications and services.

Prior authorization is a process whereby a medical provider is required to obtain pre-approval from an insurance plan before the insurer will cover the prescribed treatment or service. While 95 percent of requests are ultimately approved, this time-consuming process often results in delays in care for patients and places a significant administrative burden on providers, taking 16 hours or 2 work days per week of physician and staff time. A recent survey found that about 48 percent of rheumatic disease patients reported that their provider needed to obtain prior authorization for their prescription in the past year. Meanwhile, 87 percent of physicians reported that prior authorization has a significant or somewhat negative impact on patients’ clinical outcomes. To learn more, read the ACR’s issue brief on prior authorization.

  • The Pharmacy Benefit Manager Accountability Study Act (H.R. 1829/S. 298) is bipartisan legislation that would require pharmacy benefit managers (PBMs) to report their aggregate rebates, discounts, and other price concessions for prescriptions drugs through the Government Accountability Office (GAO). The GAO will then be tasked with issuing a report on the role of PBMs in the pharmaceutical supply chain and recommend legislative actions to lower the cost of prescription drugs. Further, the GAO would include in its report information about the use of rebates and fees, the average prior authorization approval time, and the use of step therapy within the nation’s 10 largest PBMs.

PBMs – which act as the “middlemen” between insurers and pharmaceutical manufacturers – are a major contributor to rising prescription drug costs. Unveiling the business of PBMs is necessary as they neither manufactur nor distribute treatments and yet make billions annually through the prescription drug market. PBMs have become incredibly effective at negotiating discounts and rebates, and they keep most of the savings for themselves rather than passing them on to patients as was originally intended. In addition, out-of-pocket costs and co-pays are often based on the list price of the drug rather than the PBM-negotiated price, so patients rarely see savings while PBMs profit. To learn more, read the ACR’s issue brief on PBM transparency.

Jocelyn Givens
jgivens@rheumatology.org
404-929-4810

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The American College of Rheumatology (ACR) is the nation's leading medical association for the rheumatology community and represents more than 7,700 U.S. rheumatologists and rheumatology health professionals. As an ethically driven, professional membership organization, the ACR is committed to improving healthcare for Americans living with rheumatic diseases and advocates for policies and reforms that will ensure safe, effective, affordable and accessible rheumatology care.

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