Nav: Home

American College of Rheumatology: CMS decision an affront to America's sickest Medicare patients

August 09, 2018

ATLANTA - The American College of Rheumatology (ACR) today expressed its extreme disappointment with a new Centers for Medicare and Medicaid Services (CMS) decision to allow Medicare Advantage (MA) plans to implement step therapy for Part B drugs and cross-manage Part B and D drug utilization. The policy change threatens patient access to drugs covered under Medicare Part B for the 54 million Americans living with rheumatic diseases. This policy puts insurance companies in control of patient treatment plans. Compromising medical decision making between doctors and patients prevents timely access to medications that effectively control disease.

"Put simply, this policy change is a gross affront to America's sickest Medicare patients - individuals living with diseases like inflammatory arthritis and cancer - who depend on timely access to safe, affordable, and high-quality treatments," said David Daikh, PhD, MD, President of the ACR. "Utilization management techniques like step therapy prevent and delay important treatments for rheumatic disease patients, which can result in irreversible joint or organ damage. At the same time that medical research is showing that early institution of effective treatment prevents such damage, CMS is instituting a policy that will makes it much more difficult for patients to get this treatment in time. We urge CMS to reconsider this policy and ensure that all Americans continue to have access to the most appropriate and effective therapy as determined by their health care team."

Step therapy - also known as "fail first" - is a troubling practice employed by a majority of insurers that forces patients to try therapies preferred by the insurance company before being approved for the therapy their doctor prescribed - even when doctors doubt the "insurer preferred" option will be effective. Utilized by both public and private insurers, step therapy undermines the clinical judgment of healthcare providers, leads to delays in effective therapy, and puts patients' health at unnecessary risk.

The ACR has long opposed utilization management techniques such as step therapy - in addition to others such as prior authorization, specialty tiering, and high cost-sharing - because they can prevent and delay important treatments for patients. In comments submitted to CMS last month, the ACR urged policymakers to protect patient access to Part B therapies and to instead address the issue of high treatment costs by facilitating the development of alternative payment models, expanding patient access to cost and coverage information at the time of treatment and improving FDA's capacity and manufacturer ability to bring safe, effective biosimilars to market, which will increase competition and lower costs. The ACR also supports practices continuing to negotiate better overall drug spending through Part B than what currently occurs in Part D, as suggested by HHS's own dashboard. Yet rather than addressing underlying causes of the high drug costs, this CMS policy seeks to reduce costs for insurers by limiting the ability of patients to receive the appropriate medications to treat their disease.

Furthermore, the ACR expressed concern over how these changes are being implemented and urged CMS to put any proposed changes through the formal rulemaking process so that patients and healthcare providers may be able to weigh in on the details of such a proposal.

"A change this seismic - one that has significant consequences for patient access to live-saving drugs - should go through the formal comment and rule-making process," Dr. Daikh concluded.
-end-
The American College of Rheumatology (ACR) is the nation's leading advocacy organization for the rheumatology care community, representing more than 7,700 U.S. rheumatologists and rheumatology health professionals who are committed to improving healthcare for Americans living with rheumatic diseases.

American College of Rheumatology

Related Medicare Articles:

Study: Medicare could overpay medicare advantage plans by $200 billion over ten years
Research conducted at University of California San Diego School of Medicine found that current trends in diagnostic coding for patient risk scores will lead to Medicare overpaying Medicare Advantage (MA) plans substantially through 2026-likely to the tune of hundreds of billions of dollars.
10,000 Medicare patients die in the seven days after discharge from the ED
Researchers found that, each year, about 10,000 generally healthy patients die in the seven days after discharge from the ED.
Hospitals in Medicare ACOs reduced readmissions faster
The Accountable Care Organization model of paying for health care appears to help reduce hospital readmissions among Medicare patients discharged to skilled nursing facilities, a new study suggests.
Highest out-of-pocket cancer spending for Medicare patients without supplement
Which Medicare beneficiaries shoulder the highest out-of-pocket costs after a cancer diagnosis?
Medicare's new way of paying hospitals could cause a bundle of problems for some
Hospitals that take care of the oldest, sickest and most complicated patients could suffer financially under the Medicare system's new approach to paying for some types of care, a new study finds.
Study examines opioid agonist therapy use in Medicare patients
Few Medicare enrollees appear to be receiving buprenorphine-naloxone, the only opioid agonist therapy for opioid addiction available through Medicare Part D prescription drug coverage, according to a study published online by JAMA Psychiatry.
Possible to account for disadvantaged populations in Medicare's payment programs
A new report from the National Academies of Sciences, Engineering, and Medicine says that Medicare's value-based payment programs could take into account social risk factors -- such as low socio-economic position, residence in disadvantaged neighborhoods, or race and ethnicity -- but any proposal to do so will entail both advantages and disadvantages that need to be carefully considered.
The association between Medicare eligibility and rehabilitative care
Researchers from the Center for Surgery and Public Health at BWH found that becoming Medicare eligible at age 65 (as compared to age 64) was associated with an abrupt 6.4 percentage-point decline in the number of people who were uninsured and a 9.6 percentage-point increase in rehabilitation.
Telemedicine use increases among rural Medicare beneficiaries
Telemedicine use in Medicare has been increasing rapidly, and in 2013 there were over 100,000 telemedicine visits for Medicare beneficiaries.
Study examines use of telemedicine among rural medicare beneficiaries
Although the number of Medicare telemedicine visits increased more than 25 percent a year for the past decade, in 2013, less than 1 percent of rural Medicare beneficiaries received a telemedicine visit, according to a study appearing in the May 10, 2016 issue of JAMA.

Related Medicare Reading:

Medicare For Dummies (For Dummies (Business & Personal Finance))
by Patricia Barry (Author)

Get What's Yours for Medicare: Maximize Your Coverage, Minimize Your Costs (The Get What's Yours Series)
by Philip Moeller (Author)

Medicare Made Easy: How to Make the Best Retirement Healthcare Decisions

Medicare: The Clear, Concise, Self-Educating Guide
by Mario Robertson (Author)

Medicare Made 123 Easy: Just the facts, No gimmicks, No sales pitches, Just what you need to know
by Ian Schaeffer (Author), David Schaeffer (Contributor)

Medicare Demystified: A Physician Helps Save You Time, Money, and Frustration. 2017 Edition.
by Ronald Kahan MD (Author)

The Traps Within Medicare -- 2019 Edition: How to Spot Them, How to Avoid Them, and How to Optimize Your Healthcare at the Lowest Possible Cost (“Avoid the Traps” Series, Book 2) (Volume 2)
by Mr. Rick Mortimer (Author)

Medicare Enrollment Personal Workbook: "2018 step-by-step assistance. Avoid costly penalties & pitfalls. Maximize your coverage."
by Sharon S. Campbell (Author)

Medicare: 2018-2020 The Complete Comprehensive Guide: Learn Your Insurance Options. (Business & Finance)
by Retirement & Finance Publishing

Medicare Prescription Drug Coverage For Dummies
by Patricia Barry (Author)

Best Science Podcasts 2018

We have hand picked the best science podcasts for 2018. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Where Joy Hides
When we focus so much on achievement and success, it's easy to lose sight of joy. This hour, TED speakers search for joy in unexpected places, and explain why it's crucial to a fulfilling life. Speakers include inventor Simone Giertz, designer Ingrid Fetell Lee, journalist David Baron, and musician Meklit Hadero.
Now Playing: Science for the People

#500 500th Episode
This week we turn 500! To celebrate, we're taking the opportunity to go off format, talk about the journey through 500 episodes, and answer questions from our lovely listeners. Join hosts Bethany Brookshire and Rachelle Saunders as we talk through the show's history, how we've grown and changed, and what we love about the Science for the People. Here's to 500 more episodes!