AWIR regularly tracks legislation and regulation of impact to our rheumatologists at both the state and federal level. Below you will find information on AWIR’s policy priorities along with state maps showing which issues have been active in your state and at the federal level.
Each year patients are affected by formulary driven switching for non-medical reasons. This issue has become such a common practice among insurer’s and Pharmacy Benefit Managers (PBMs) that there is now legislation aiming to help patients affected by this harmful practice.
AWIR believes that medically stable patients should not be switched off of their medication for non-medical reasons at any point during their plan year and that the patient should be grandfathered with year over year protections. Legislation that AWIR supports would prohibit a patients drug from being removed from the formulary or moved to a more restrictive or costly tier unless the drug was to be deemed unsafe by the FDA.
This utilization management tool prohibits patients from accessing a drug prescribed by their doctor until they fail on the preferred drug or set of drugs covered by their health plan. Unfortunately, a lot of states do not have exceptions in place to bypass this process if there is medical evidence proving the patient has already failed those drugs or they have a medical issue where it would be harmful for them to take that medication.
AWIR supports step therapy/fail first legislation that is regulated by nationally recognized clinical practice guidelines, provides physicians the authority to override step therapy protocols based on a patient’s medical history and the override protocols should be clear and abbreviated. The State Access to Innovative Medicine (SAIM) Coalition has produced model language that AWIR supports as the national standard for step therapy/fail first legislation.
Prior authorization refers to an insurance company policy requiring medical providers to obtain the insurer’s approval before it provides coverage for certain medications and treatments. In some states, insurers are allowed to set their own prior authorization processes, which may vary from insurer to insurer, creating confusion. Each different insurer may have dozens of different prior authorization forms depending on the insurance plan.
The national time cost to practices of interactions with health insurers is estimated between $23 billion to $31 billion annually. Studies of medical practices’ interactions with health insurers show that to administer insurance each year, the average provider’s office requires 3 weeks of the provider’s time, 23 weeks of nursing staff time, and 44 weeks of clerical staff time.
AWIR supports uniformed prior authorization legislation that (1) requires insurers to use the uniform prior authorization form, adopted by the Department of Insurance, for prescription medications, medical treatments and procedures (2) requires the form to be electronically accessible and able to be submitted electronically (3) Deem authorization granted if an insurer fails to respond to or accept the uniform prior authorization form within 5 business days or, for urgent requests, 1 business day upon receipt of a request.
As biosimilars come to market along with the ability to be deemed interchangeable, states around the country will need to update their state substitution laws to include these new and innovative drugs.
AWIR supports legislation that would allow a pharmacist to substitute an FDA approved interchangeable biosimilar for a prescribed originator biologic as long as the prescriber is notified through some means of communication that the substitution has occurred within 5 business days. The product must be deemed interchangeable by the FDA and the prescriber must have the ability to write “dispense as written” (DAW).
In 2015, Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA) with bipartisan support, and backing from physicians, to promote and incentivize both quality and value in the delivery of health care services for Medicare beneficiaries.
Under MACRA, most physicians will initially fall under the Merit-based Incentive Payment System (MIPS) program for the Medicare payments they receive for physician services. MACRA consolidated the multiple previous reporting requirements into MIPS as a single program. Based on aggregate scores that physicians receive each year under MIPS they may receive either a bonus or a penalty in their reimbursement. Congress specified in the statute that payment adjustments are budget neutral and is set at plus or minus 4% in 2019 and rise to plus or minus 9% from 2022 onward.
AWIR is closely monitoring this new program and is providing feedback to CMS that best represents our specialty.
According to a 2017 report by the Association of American Medical Colleges (AAMC), the United States will face an overall shortage between 40,000-104,00 physicians by 2030. Specialty shortages will be particular large, including rheumatology.
The American College of Rheumatology (ACR) conducted a study in 2005 that examined the number of adult practicing rheumatologists in the United States and estimated there to be roughly 1.7 adult rheumatologists per 100,000 persons. As the number of rheumatologists has continued to decline since then and the population ages, many believe the shortage could grow as high as 2,500 by 2025.
Growth in future demand for physicians will be the highest among specialties that predominantly serve the elderly. AWIR understands the need to address this issue and is supporting legislation that promotes the development of rheumatologists in the United States.
Resident Physician Shortage Reduction Act H.R. 2267/S. 1301 – Improves the nation’s GME system and helps to preserve access to specialty care by:
1. Increasing the number of Medicare-supported GME residency slots by 15,000 over the next 5 years.
2. Directing half of the newly available positions to training in shortage specialties.
3. Specifying priorities for distributing the new slots (e.g. states with new medical schools).
4. Studying strategies to increase the diversity of the health professional workforce.
Drug pricing has been a major issue in recent years that has continued to affect our patient’s ability to obtain their specialty medication. To confront this issue AWIR has joined the Alliance for Transparent and Affordable Prescriptions (ATAP) who has been tasked to contest transparency in drug pricing on the state and federal level on behalf of patients and providers.
The goal of ATAP is two-fold: one, to educate physicians, patients, legislators, and the general public about PBMs and their role in the prescription drug market, with the goal of bringing awareness to the impact PBMs have on drug costs and access to treatment; and two, to ensure patients have access to effective and affordable medication therapies by developing and implementing a comprehensive advocacy plan that seeks to increase transparency and further regulate PBM practices through legislation and public policy at both the state and federal levels.