CSRO continues to receive reports from practices around the country about biosimilars costing more to acquire than payers will reimburse, affecting the ability to use those treatments. (See CSRO's initial overview here.)

To aid in addressing this with payers, CSRO is drafting a resource document and needs your help. If your practice acquires medications for in-office administration and has been affected by this situation, please complete this brief survey.

Responses will allow CSRO to quantify the extent of the problem and to potentially include this data in the resource document. If there are any questions, email info@csro.info.

Finalized MA, Part D Policies Mixed Bag for Rheumatologists and Patients

In its CY 2025 Policy and Technical Changes for Medicare Advantage and Part D Plans, the Centers for Medicare and Medicaid Services (CMS) finalized policies to address marketing of MA and Part D plans, including supplemental benefits. According to its fact sheet, CMS has redefined “compensation” to set a clear, fixed amount that agents and brokers can be paid regardless of the plan the individual enrolls in, addressing loopholes that result in commissions above this amount that create anti-competitive and anti-consumer steering incentives.

The fact sheet also notes that CMS will require MA plans to issue a “Mid-Year Enrollee Notification of Unused Supplemental Benefits” on supplemental benefits not accessed by the enrollee during the first six months of the year, including instructions on how to access the benefit, among other things. CSRO supported these changes in comments.

CMS also finalized policies that CSRO strongly opposed, including that Part D sponsors may treat formulary substitutions of all biosimilars for their reference products as “maintenance changes” that would not require explicit prior approval by CMS and that Part D sponsors can immediately substitute a new interchangeable biological product for a reference product and provide notice of the change to affected enrollees after making such change. CMS believes these policies improve enrollee access to medications, including biosimilars, but rheumatologists have concerns about patient safety when medications are switched for non-medical reasons, and usually for the financial gain of the payor. Read more in the final rule.

CSRO Weighs in on Medicare Reimbursement Reform Discussion

The need for long-term reform of Medicare physician reimbursement has become more than apparent, given the recurring need for Congress to mitigate year-end payment reductions. On April 11, the Senate Finance Committee held a hearing entitled, “Bolstering Chronic Care through Medicare Physician Payment.” In his opening remarks, Chairman Wyden (D-OR) highlighted the fact that Medicare Advantage plans will reportedly spend six billion dollars a year on marketing middlemen.

One of his goals is to have traditional Medicare keep up with the needs of beneficiaries when it comes to care coordination. Ranking Member Crapo (R-ID) discussed the fact that Fee Schedule payments have declined by over 25% in inflation-adjusted terms over the past two decades and that the conversion factor update schedule cannot sustain an effective or even adequate clinical workforce to meet the needs of beneficiaries. That echoed the points CSRO made in a recent submission to the bipartisan Senate working group on Fee Schedule reform, which we submitted to the Finance Committee hearing record as well.

On the same topic, the Medicare Payment Advisory Commission (MedPAC) recently discussed policy approaches that could be taken to update Medicare payment to physicians, including an update to the practice expense component of the Fee Schedule by the hospital market basket index minus productivity; annually updating the Fee Schedule by the Medicare Economic Index (MEI) minus one percentage point, with a floor of ½ of MEI; and extending the bonus for clinicians in Advanced Alternative Payment Models (APMs), which is currently set at 1.9%. The Commission will include information about these approaches in the June 2024 Report to the Congress, and continue refinements in the next cycle beginning in the Fall. CSRO will monitor and share additional updates as appropriate.

CSRO’s virtual Business of Rheumatology seminar series to help support rheumatology practices in building and strengthening their business has returned!

Log in on May 1 to hear from a diverse panel of rheumatologists sharing insights on starting and optimizing a practice, facilitated by experienced independent practitioners CSRO President Dr. Gary Feldman and Vice President & Secretary Dr. Aaron Broadwell:

• Giorgos Loizidis, MD: Southern Oregon Rheumatology Clinic, OR
• Sunny Patel, MD: DFW Rheumatology, TX
• Nandini Setia, MD: Articularis Rheumatology Specialists. GA

Last week Virginia’s Governor vetoed SB 274, which would have established a Prescription Drug Affordability Board (PDAB) with the power to set upper payment limits. As it was written, the legislation would have had a significant impact on rheumatologists’ ability to recoup appropriate reimbursement for drugs they administer, which would limit access for patients.

CSRO Board member Dr. Harry Gewanter led advocacy activities in the state including features in local news and TV (pictured above) and developing a sign-on letter with more than 70 Virginia physicians, all urging the Governor to veto the bill.

This was a hot-button topic, with significant pressure coming from the opposite direction, and these combined efforts had a direct impact on the successful outcome. It is likely that this issue will be active in the legislature again next year, and CSRO will continue to engage with the Virginia rheumatology community to advocate for patient access to rheumatological care. 

Alternative funding programs, which eliminate a patient’s specialty drug coverage for the purpose of enrolling them in charitable patient assistance programs, have emerged as an increasingly prevalent access challenge for patients. In order to raise awareness and take action on the issue, CSRO spearheaded the introduction of HB 509 in Louisiana.

On April 16, that legislation received an informational hearing in the House Insurance Committee. CSRO attended that hearing to educate legislators on what alternative funding programs are and how they impact patients (pictured above). Substantive action on the bill was deferred until the following week to consider the best path forward. 

"Mississippi ranks dead last in health outcomes out of all 50 U.S. states. As a longtime advocate for access to rheumatology care and a physician, I am seriously concerned about this trend especially since more than 27% of adults in Mississippi live with arthritis, a condition treated by rheumatologists."

Read more from CSRO's Vice President of Advocacy & Government Affairs Dr. Madelaine Feldman in this Mississippi Business Journal letter to the editor highlighting issues with the proposed expansion of the state's 340B Drug Pricing Program.

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 of CSRO priority bills.

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

California

Rebate Pass Through

• SB 966: Set for hearing 4/24

Kentucky

White Bagging

• HB 190: Delivered to the Governor
• SB 188: Signed by the Governor

Missouri

Gold Card

• HB 1976: Passed the House and transmitted to the Senate

White Bagging

• HB 2267: Passed the House, transmitted to the Senate 

New Hampshire

Accumulators

• SB 354: Hearing scheduled for 5/1

Rebate Pass Through

• SB 555: Public Hearing scheduled 4/30

Virginia

Prescription Drug Affordability Board

• SB 274: Vetoed by the Governor
• HB 570: House sustains Governor’s veto 

Business of Rheumatology: May 1, 2024

CSRO's virtual seminar series to help support rheumatology practices in building and strengthening their business returns for another year.

Virtual Advocacy Day: July 10, 2024

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

CSRO Advocacy Conference: September 20-22, 2024

Gather with others in the rheumatology community in Nashville for CSRO's annual Advocacy Conference! 

State Society Conferences:

CSRO's state rheumatology society members host their own annual meetings throughout the year. Find a listing of these state-specific conferences on our website.

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.

Career Center

Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.

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.

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.

Rheum for Action

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

Step Therapy Cover Sheets

Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.

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.