ACR Urges HHS to Reform Policies on Part B, Prior Authorizations

February 1, 2018
Samantha DiGrande

The American College of Rheumatology (ACR), which represents over 9500 rheumatologists and rheumatology health professionals, recently submitted a letter to HHS in response to the department’s request for information on Promoting Healthcare Choice and Competition Across the United States.

The American College of Rheumatology (ACR), which represents over 9500 rheumatologists and rheumatology health professionals, recently submitted a letter to HHS in response to the department’s request for information on Promoting Healthcare Choice and Competition Across the United States.

In the letter, the ACR applauded CMS’ recent decision to assign unique J-codes to each biosimilar of a reference product and encouraged HHS to continue to support biosimilar innovation. Allowing biosimilars to have their own unique J-code ensures better monitoring of their effectiveness while allowing for sufficient pharmacovigilance.

ACR urged Congressional leaders to reverse a recent decision to adjust providers’ reimbursement for Part B drug costs based on their performance under the Merit-Based Incentive Payment System (MIPS), despite these drugs’ costs being outside physician control. ACR claims that both reforms are essential to advancing the current administration’s goals of promoting healthcare choice and competition.

“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. This is in direct conflict with the Administration’s goal of promoting patient choice,” said David Daikh, MD, PhD, president of ACR, in a statement.

ACR also called on HHS to address the problem of prior authorizations. The letter cites a 2016 American Medical Association (AMA) survey that found that medical practices on average complete 37 prior authorization requirements per week, per physician. This process takes about 16 hours (or 2 full business days). ACR says that CMS (and other entities that are engaged in reform) should follow a group of principles outlined in the letter:

  • Require Part D plans to accept and respond to prior authorization and override requests electronically
  • Accelerate automation of medical services by issuing a ruling and enforcing current health plan compliance regulations
  • Ensure that utilization management requirements are not solely based on cost
  • Require plans to electronically disclose drugs and medical services subject to coverage restrictions
  • Require a 60-day grace period for utilization management requirements when a patient changes health plans
  • Require plans to follow prior authorization decisions and pay for services
  • Ensure that prior authorization not be required for drugs that are standard treatment for a condition
  • Ensure that any “peer-to-peer” reviews are conducted by physicians within the same specialty as the ordering physician
  • Restrict prior authorization requirements to “outlier” providers
  • Do not allow Part B services to be subject to prior authorization requirements

“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. 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,” said Daikh.

Another area of concern for ACR is the need for increased transparency from pharmacy benefit managers (PBMs). The ACR suggested that CMS consider policies that provide more transparency about PBMs payment practices, including the true cost of drugs. ACR also encouraged HHS to require more consistency in the way PBMs structure their rebate programs, including uniform definitions for terms used in disclosures, such as specifying what constitutes a rebate, discount, fee, and amount received from a manufacturer.

Along with ACR, more than 100 healthcare organizations sent letters to congressional leaders urging them to reverse the CMS policy, cautioning that it will create a tremendous financial risk for specialists that administer Part B drugs and lead to significant access problems for patients that rely on these therapies.

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