Debt Ceiling Deal

The recent debt ceiling deal suspends the debt limit until January 2025. Among other provisions, it holds discretionary spending to caps enforced by sequestration. There have been conflicting reports on how this would be executed, but the latest and most reliable information is that, if triggered, sequestration wouldn’t be ordered until April 30, 2024.

It is important to note that this sequestration would affect only discretionary spending. Mandatory programs like Medicare would be unaffected, so physicians will not be absorbing any new sequestrations to Medicare Part B reimbursement as a result of the debt ceiling deal. CSRO will continue to monitor and provide updates as appropriate.

MedPAC Recommendations

In its June 2023 report to Congress, the Medicare Payment Advisory Commission (MedPAC) included several recommendations related to Part B drug administration. In addition to payment reforms targeted to drugs approved pursuant to FDA’s accelerated approval program, MedPAC also recommended two policies that would be applicable to all Part B drugs.

First, MedPAC recommended establishing a single, average sales price-based payment rate for Part B drugs with “similar health effects.” The details of what is a “similar” health effect would be left to the Department of Health and Human Services to determine, which is concerning. Second, MedPAC recommended reducing the percentage-based add-on payment to ASP for costly Part B drugs. MedPAC did not recommend a specific approach to do so, but illustrated a model in which the current ASP add-on of 6% would remain at the same level for “lower-priced” drugs, the percentage would be reduced and a fixed fee would be added for “mid-priced” drugs, and the percentage would be replaced entirely with a fixed-dollar cap for the “highest-priced” drugs.

It is important to remember that, MedPAC has no legislative authority; it merely makes recommendations for Congress to consider. Even so, reducing the add-on payment would amount to yet another reduction in physician reimbursement and may leave practices underwater for certain medications. CSRO plans to engage the congressional committees of jurisdiction to express our concerns and to hopefully ensure that these recommendations do not move forward. In the meantime, view a short video highlighting CSRO's concerns here.

Help ensure that the issues impacting you and your practice are shared with members of Congress – advocate alongside CSRO during our Virtual Advocacy Day in July!

CSRO is calling on rheumatologists from around the country to join us as we discuss issues of interest to the rheumatology community with health care leaders from the U.S. House of Representatives and U.S. Senate.

These live conversations will be held through Zoom on Thursday, July 13 and participants are welcome to attend all or part of the day. Legislation being discussed includes the Safe Step Act, HELP Copays Act, and Protecting Patients Against PBM Abuses Act; visit our website to learn more and sign up today.

Joining Louisiana and North Dakota as the third state in the nation to enact protections against specialty pharmacy mandates, Texas signed HB 1647 into law this month.

Specialty pharmacy mandates, commonly referred to as “white bagging”, is a trend among payers that seeks to replace the buy and bill system with a “white bagging” acquisition system that requires physicians to receive medication from a specialty pharmacy, which will be shipped to their office for administration. This type of model results in practices having no control over the handling, preparation, and storage conditions of a drug prior to its administration.

This new law, which goes into effect on September 1, 2023, helps to prevent insurers from mandating white bagging by:

• prohibiting requirements that drugs be dispensed by certain pharmacies
• prohibiting the exclusion of coverage for a drug because it is not dispensed by a pharmacy selected by a health benefit plan
• protecting patients from increased costs as a result of a provider using buy and bill
• prohibiting a requirement to bill or be reimbursed under the pharmacy benefit without patient and provider consent

Once the law has gone into effect, CSRO will provide additional details and resources – stay tuned for more information.

Vertically integrated pharmacy benefit managers (PBMs) and insurers are attempting to convince policymakers and the business community that state PBM reform will increase health insurance costs and interfere with the administration of employer-sponsored health plans.

To counteract these inaccurate claims, a stakeholder letter has been created by friends of the Coalition of PBM Reform, of which CSRO is a member. We encourage your state societies and practices to sign on to this letter and help remind Congress that the rheumatology community strongly supports PBM reform and there is no evidence to support the claims being made by PBMs and insurers.

Health Insurance too Often Fails to Make the Grade

A new report scoring insurers and pharmacy benefit managers (PBMs) shows that most plans have barriers in place to make it harder for patients living with autoimmune conditions to access their doctor-prescribed medicines.

Learn more in this piece from the Virginian-Pilot, co-authored by CSRO Board Member Dr. Harry Gewanter. 

Permission to Prescribe – PBMs have too much Control

Pharmacy benefit managers (PBMs) directly impact drug prices and have unchecked control over the amount patients pay for their prescriptions, as well as what drugs are accessible to the public.

Learn more in this video featuring CSRO Vice President of Advocacy & Government Affairs Dr. Madelaine Feldman explaining the issue.

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report.

Be sure to check out our interactive legislative map tool for additional details.

CALIFORNIA

Rebate Pass Through

• SB 873: Referred to Assembly Health committee

Biomarker Testing

• SB 496: Passed the Senate, referred to Assembly Health committee

LOUISIANA

Biomarker Testing

• SB 104: Signed by the Governor

NEW YORK

Biomarker Testing

• S1196: Passed the Assembly, returned to the Senate

OHIO

Accumulators

• HB 177: Re-referred to Public Health Policy committee

TEXAS

Accumulators

• HB 999: Signed by the Governor

White Bagging

• HB 1647: Signed by the Governor 

Virtual Advocacy Day: July 13, 2023

Advocate alongside CSRO as we host live conversations with health care leaders from the U.S. Senate and U.S. House of Representatives.

Advocacy Conference: August 25-27, 2023

Join us in Austin for our Advocacy Conference and celebration of our 20th Anniversary! 

Business of Rheumatology: October 4, 2023

Don't miss the third seminar in CSRO's virtual series which will discuss advanced practice providers (APPs) and the workforce. Details and registration coming soon.

Action Center

Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly

Advocacy Council

Amplify your voice by assembling with other like-minded individuals to enhance CSRO’s advocacy initiatives.

Legislative Map Tool

Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.

Rheum for Action

Learn about the latest advocacy issues in CSRO's advocacy column produced in partnership with Rheumatology News.

Payer Issues Reporting Form

Request assistance with any payer relation issues that may be impacting your patients or office.

Policy Correspondence

Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.

CSRO is a 501c3 nonprofit organization that has remained dedicated to ensuring access to the highest quality care since 2003 – donate today.

Questions?

Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.