233 Members Urge Congressional Doc Fix

In a letter to Speaker Mike Johnson (R-LA-04) and House Minority Leader Hakeem Jeffries (D-NY-08), 233 bipartisan members of the House of Representatives urged congressional leadership to stop the proposed 2.8% Medicare Physician Fee Schedule cut for physicians from going into effect. CSRO contacted over 100 members of the House encouraging them to join this letter and address the Medicare Physician Fee Schedule during the lame-duck session. CSRO also supports several bills that would address long-term fixes to the program and will continue to advocate for those bills while also urging an immediate short-term fix before year’s end.

Carter and Barragan Lead Maximizer Ban Campaign

Representatives Buddy Carter (R-GA-01) and Nanette Barragan (D-CA-44) are leading a Congressional sign-on letter addressed to the Departments of Health and Human Services (HHS), Labor, and Treasury (tri-agencies) urging the tri-agencies to issue the proposed rule extending the provision of the 2025 NBPP. This provision would effectively end the practice of copay maximizers to all non-grandfathered plans. Without this additional proposed rule, the NBPP only applies to individual and small group plans. The tri-agencies said they would issue a proposed rule in April 2024, although nothing has been released to date.

Reps. Carter and Barragan are the House leads on the HELP Copays Act, which would codify a prohibition on the use of copay accumulators in plans on the health insurance Exchange. The bill boasts 140 cosponsors in the House and 17 cosponsors in the Senate. The legislation is important even if the tri-agencies adopt the provision in the 2025 NBPP on copay maximizers to ensure that future administrations uphold these patient protections.

Join CSRO during ACR Convergence 2024 in Washington, D.C. for an exclusive Member Breakfast on Sunday, November 17 to converse with others in the rheumatology community about challenges you may be facing and to discuss your state society's priorities for the year. Registration is required – sign up now!

CSRO Member Breakfast

Sunday, November 17

7:00am ET

Please note: this is not an official function/event of the American College of Rheumatology.

Join CSRO as we gather with the rheumatology community for a virtual Town Hall to share updates on CSRO's state, federal, and regulatory advocacy work.

The program will feature CSRO's Government Affairs team as they provide insights on the Medicare Physician Fee Schedule, utilization management reform, down coding, the SAD List, and more!

Hear from our team in DC on a post-election analysis of what we can expect during the lame duck and upcoming 119th Congress. Attendees will also receive an insider look at state and federal priority issues for the year ahead and a review of new laws going into effect on January 1.

CSRO Town Hall

November 20, 2024

7pm CT / 8pm ET

Help rheumatology fellows as they prepare for their future roles as physicians by encouraging them to attend CSRO's 2025 Fellows Conference – an annual event curated by rheumatologists specifically for rheumatology fellows.

This professional development opportunity is free and CSRO provides expense reimbursement for rheumatology fellows, residents planning to pursue a rheumatology fellowship, and practitioners 1-3 years out of fellowship who have not attended the event before.

Share this email with the fellows in your network so they can be a part of this can't-miss event!

In recent meetings with the Centers for Medicare & Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC), the joint ACR-CSRO Underwater Biosimilars Coalition raised awareness to significant challenges patients, including Medicare beneficiaries, face accessing biosimilar medications administered in office and hospital settings.

Specifically, the Coalition highlighted the disconnect between the high acquisition costs of biosimilar therapies and the low reimbursement rates under the average sales price (ASP) methodology, as well as the impact of “step therapy” policies that prevent patients from accessing an alternative drug when the biosimilar is “underwater.” Both agencies understood the challenges; CMS highlighted its CY 2025 Medicare Physician Fee Schedule (PFS) proposals that aim to mitigate the issue.

The Coalition will communicate its concerns and potential solutions with the White House Office of Management and Budget (OMB) and Congressional leadership, over the coming weeks.

Last week, the Coalition of State Rheumatology Organizations (CSRO) submitted a letter to the Centers for Medicare and Medicaid Services (CMS), urging an increase in the Medically Unlikely Edit (MUE) for golimumab (J1602). MUEs are claim edits designed to prevent billing errors and reduce fraud by flagging claims where the quantity of services or medications appears excessive or clinically implausible.

In the letter, CSRO explains that patients with obesity often require a dose that exceeds the current MUE of 300 units, however, “rheumatologists that administer golimumab to these patients are finding themselves in one of two situations: 1) either they face claim denials that must be appealed in order to be reimbursed for their costs, adding to the financial strain and administrative burden on physician practices, or 2) they must give a dose that is inappropriately low based on FDA recommendations, delaying evidence-based treatment for individuals who already experience significant disability and health challenges.”

CSRO also raises concerns about the impact of this claim edit on health equity, noting it could be perceived as discriminatory when patients are also disabled. CSRO is urging CMS to increase the MUE to 400 units to address these challenges.

CSRO, in coordination with advocates from the State Access to Innovative Medicines (SAIM) Coalition, is advocating for prior authorization reform legislation that will improve patient access and remove administrative burdens that hinder care.

If you haven't already, please complete this survey to help us better understand the challenges prior authorization puts on your practice and patients! Your feedback will enable us to identify the most burdensome aspects of this process and explore potential improvement solutions.

New Jersey: Step Therapy Legislation Advances

The New Jersey Senate Commerce Committee unanimously advanced S.3533, which would protect patients from excessive step therapy by creating an exceptions process that would allow patients to appeal step therapy protocols in cases where they are clearly inappropriate. CSRO submitted a slip in support during the hearing and submitted comments to the Committee endorsing the bill, which:

• Ensures step therapy protocols are based on medical & clinical guidelines
• Establishes a clear and expeditious exception process
• Allows a prescriber to override a step therapy protocol under certain circumstances
• Creates consistent determination timelines

The New Jersey Association of Health Plans proposed amendments that would have gutted the bill, but the legislation was released unamended and with the CSRO-supported language. The bill has now been referred to the Senate Budget & Appropriations Committee. Since New Jersey is in the first year of its two-year session, the bill is able to advance through January 2026.

Maryland: UPL Action Plan Awaits Consideration

The Maryland Prescription Drug Affordability Board approved and submitted its UPL Action Plan to the state’s Legislative Policy Committee. CSRO submitted comments in August to the Maryland PDAB regarding serious concerns over their plan to implement a UPL and resubmitted its concerns to the Legislative Policy Committee in October. The Committee has until October 25 to review and act on the plan. The PDAB cannot execute UPL authority without legislative approval. 

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. 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.

CSRO Town Hall: November 20, 2024

Join CSRO as we gather with the rheumatology community for a virtual Town Hall to share updates on CSRO's state, federal, and regulatory advocacy work.

Business of Rheumatology: December 4, 2024

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

CSRO Fellows Conference: February 21-23, 2025

An annual event to help rheumatology fellows prepare for their future roles as practicing rheumatologists.

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.

Explanatory Statement: “Underwater” Biosimilars

To aid in addressing the issue of "underwater" biosimilars with payers, CSRO has created a document to illustrate the extent of the problem.

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 authored by Dr. Madelaine Feldman and 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.