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Rheumatology Community Urges CMS to Withdraw or Significantly Modify Part B Payment Demo, Citing Devastating Impact to Rheumatology Patients and Providers

WASHINGTON, D.C. – The American College of Rheumatology (ACR) today submitted detailed comments to the Centers for Medicare & Medicaid Services (CMS) in response to the agency’s controversial Part B payment proposal. The comment letter urged CMS to withdraw or significantly modify the proposal due to the devastating impact it would have on rheumatology patients who rely on Medicare Part B to access needed biologic therapies.

“Many rheumatologists have already been forced to stop administering biologic therapies to Medicare patients because the current Part B payment structure does not cover the costs of obtaining and providing these complex therapies in the outpatient setting,” the letter states. “Additional cuts will force rheumatologists to send patients elsewhere to get the same drugs, often at increased cost and burden to the patient.” The letter further explains that patients will face more expensive co-pays and facility fees, longer travel, administration of therapies absent the supervision of their rheumatologist, and increased risk of death from infusion reactions under the new proposed payment test.   

A Flawed Cost-Savings Premise

The ACR also criticized the “one-size-fits all” approach to the Part B payment proposal, saying it would not achieve the intended effect of lowering Medicare costs for rheumatology care over the long term.

“The underlying proposal relies on reducing Part B drug pricing by encouraging physicians to prescribe lower cost products, but less expensive alternatives do not exist for Part B for rheumatology patients,” the letter states. “We understand and share the concern regarding the rising costs and spending associated with drugs and biologics. However, rather than reducing costs to Medicare, this proposal will likely cause a see-saw effect whereby reimbursement decreases for physicians, physicians then stop offering in-office infusion treatments because Medicare’s reimbursement is insufficient, and patients therefore seek infusion treatment at hospitals where Medicare’s costs are higher.  Such a result runs counter to the new innovative payment delivery reforms that CMS has been seeking to promote through the Medicare Access and CHIP Reauthorization Act (MACRA).”

“While we can control for many factors over the course of the treatment, we cannot control how drug manufacturers set their prices,” the letter continues. “Further, unlike the wide array of treatment options available to most specialties, our patients and physicians have a limited number of drug and biologic treatments available.”

Modifications Required to Protect Patients

The comment letter emphasizes withdrawal of the proposal and includes a detailed list of significant modifications that would need to be made to the Part B proposal in order to mitigate the access challenges for rheumatology patients.

“If the proposed new methodology is implemented, we request that CMS begin by implementing the methodology in a limited geographic area to evaluate and identify weaknesses of the methodology, including issues of beneficiary access, before implementing the model nationally,” the letter states.

CMS must evaluate changes to the Part B program in a much smaller demonstration project that evaluates the availability of quality and affordable services, availability of alternative therapeutic products with price differentials, and phasing in changes to allow adjustment of operations to ensure that beneficiaries’ access to care is not disrupted, the letter explained.

Second, CMS must align or consider MACRA timeframes and changes, and the impact of these changes.

Finally, CMS must establish key exemptions to protect the most vulnerable Medicare beneficiaries. Suggested exemptions include physician groups of 25 or fewer professionals, physician-owned practices located in rural and medically underserved areas, drugs (including biologics) that have no alternative with more than a 20 percent ASP differential, and drugs (including biologics) where there are three or fewer members of the drug/biologic class available under Part B.

“We share CMS’s goal of providing patients with cost-effective treatment, but effectiveness can be measured in many ways. Further, for chronic illnesses, like rheumatic diseases, effectiveness must be measured over the long term. Medicare must recognize that a proposal that may reduce costs now, but results in longer-term treatment costs for its beneficiaries, has not benefited the beneficiary or Medicare,” the letter concludes.

For more information, see the full text of the comment letter. 

Erin Schmidt


About the American College of Rheumatology

The American College of Rheumatology (ACR) provides education, research, advocacy and practice management support to more than 6,400 U.S. rheumatologists and rheumatology health professionals. In doing so, the ACR advocates for high-value, high-quality healthcare policies and reforms that will ensure safe, effective, affordable and accessible rheumatology care.

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