Press Releases

Rheumatology Leaders to HHS: Prior Authorization, Recent Part B Payment Change Are Biggest Threats to Healthcare Choice and Competition

WASHINGTON, D.C. – In its response to the U.S. Department of Health and Human Services’ latest Request for Information on Promoting Health Care Choice and Competition Across the United States, the American College of Rheumatology (ACR) urged HHS to reform its prior authorization policies and to work with Congressional leaders to reverse a recent HHS decision to apply Part B drug spending to payment adjustments under the Merit-Based Incentive Payment System (MIPS).  Both reforms are key to advancing the Administration’s goals of promoting healthcare choice and competition, rheumatology leaders said.

According to a 2016 survey from the American Medical Association, medical practices complete an average of 37 prior authorization requirements per week per physician, which takes an average of 16 hours to process – the equivalent of two full business days.

“The current prior authorization process leads to a waste of valuable resources that delays care and does not add value to the healthcare delivery system,” said Dr. David Daikh, MD, PhD, President of the ACR. “We encourage HHS and all agencies involved in utilization management to follow a set of best practices that ensure utilization management programs are reasonably designed and implemented.”

Recently, the ACR joined several leading organizations representing physicians, hospitals, pharmacists, medical groups and patients, to develop a set of prior authorization and utilization management reform principles that are intended to serve as a guide for reasonable reform of existing utilization management programs.

The ACR also urged HHS leaders to work with Congress to reverse a recent Centers for Medicare & Medicaid Services (CMS) decision to adjust providers’ reimbursements for Part B drug costs based on their performance in MIPS, despite the fact that these drug costs are outside of the control of the physicians.

“This dangerous policy penalizes the doctors who administer Part B therapies and will ultimately reduce patient access to treatments for diseases like arthritis and cancer, particularly in rural and underserved areas of the United States,” said Dr. Daikh.  “This is in direct conflict with the Administration’s goal of promoting patient choice.”

Earlier this month, the ACR and more than 100 healthcare organizations sent letters to Congressional leaders urging them to reverse the CMS policy, warning that it creates enormous financial risk for specialists who administer Part B drugs and will lead to significant access issues for patients who rely on these therapies.  CMS included the policy change in its CY 2018 Quality Payment Program Final Rule despite repeated warnings from healthcare advocates and Congressional leaders.

According to a recent Avalere Health analysis, certain specialties that prescribe Part B drugs – including rheumatology, oncology, and ophthalmology – could see payment cuts as high as 29 percent under the policy change.

Other issue areas the ACR commented on include:

  • PBM Transparency: The ACR urged CMS to consider policies that require PBMs to be more transparent about their payment practices, including transparency around the true cost of prescription drugs. While they were created to control costs, consolidation of the industry and an overall lack of transparency has allowed PBMs to become increasingly effective at keeping the savings they negotiate from drug companies. This practice has driven up co-pays and out-of-pocket costs for patients. HHS should require more uniformity in the ways PMBs structure their rebate programs, including uniform definitions for terms used in disclosures by specifying what constitutes a rebate, discount, fee, and amount received from a manufacturer.
  • Unique J-codes for Biosimilars: The ACR encouraged HHS to continue to support biosimilar innovation and applauded CMS’ recent decision to assign unique J-codes to each biosimilar of a particular reference product. Doing so allows physicians to better track and monitor their effectiveness while ensuring adequate pharmacovigilance. Assigning unique J-codes also ensures that the drugs are not identified based on cost and accelerates their market uptake, furthering competition and leading to lower drug costs for patients.

“We appreciate HHS creating this opportunity to provide feedback on reforms that could result in a better, more efficient healthcare system,” Dr. Daikh continued. “Laws, policies and regulations should allow providers to focus on medical decision-making without creating additional burdens that restrict patient access and limit choice.” 

Jocelyn Givens
jgivens@rheumatology.org
404-633-3777, ext. 810

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The American College of Rheumatology (ACR) is the nation’s leading advocacy organization for the rheumatology care community, representing more than 6,400 U.S. rheumatologists and rheumatology health professionals. As an ethically driven, professional membership organization committed to improving healthcare for Americans living with rheumatic diseases, the ACR advocates for high-quality, high-value policies and reforms that will ensure safe, effective, affordable and accessible rheumatology care.