Updates from Capitol Hill | |
Congress Asks PBM Executives to Correct Record | |
|
House Oversight and Accountability Chairman James Comer (R-KY) has written to pharmacy benefit manager (PBM) executives accusing them of providing false testimony before the committee during a July hearing.
Comer argues that statements made by CVS Health Corp., UnitedHealth Group Inc, and Cigna Group contradict findings by the committee and the Federal Trade Commission (FTC). The PBMs repeatedly asserted that they do not steer patients to their own pharmacies or pay affiliated pharmacies more favorable rates. Comer asks the three executives to “correct the record” by September 11, and CSRO will continue to monitor.
| |
CSRO Urges Congress to Advance Safe Step Act | |
|
As we prepare for Congress’ return from summer recess, CSRO is joining efforts with patient advocates in a letter to Congressional leadership encouraging inclusion of the Safe Step Act (S.652) in any final PBM or end-of-year package.
The Safe Step Act ensures that employer health plans, including their contracted PBMs, offer an expedient and medically reasonable step therapy exceptions process. The Safe Step Act is endorsed by over 215 patient and provider organizations and is modeled after legislation that has passed in 38 states. CSRO also shared this opportunity with member societies encouraging their participation.
| |
CMS Resource: G2211 Guidance Published | |
|
Practicing rheumatologists have anticipated the release of CMS’ guidance on HCPCS code G2211, an “add-on” code that became payable at the outset of CY 2024. The recently published FAQ document provides some clarity on use of this code, including questions related to the documentation requirements for G2211.
Separate from the FAQ, CMS staff in the Office of the Administrator (OA) responded to questions about Medicare Advantage payment for G2211, confirming that "plans can decide how they want to pay for [G2211]," which could mean bundling the service. CMS OA staff also noted that providers “could negotiate with plans to be reimbursed for [G2211],” or negotiate a value-based contract that might cover the complex care, as described by the add-on code.
| |
CSRO Comments on CY 2025 MPFS Proposals: Leads Coalition Effort on “Down Coding” | |
|
This week, CSRO responded to CMS’ CY 2025 Medicare Physician Fee Schedule (PFS) proposed rule, submitting comprehensive comments that address key issues affecting rheumatology practices, including ongoing challenges related to the “down coding” of complex drug administration services, “underwater” biosimilars, and a problematic rheumatoid arthritis cost measure planned for inclusion in the MIPS program starting in CY 2025.
CSRO has also been at the forefront of addressing the inappropriate "down-coding" of complex drug administration services, an issue that has significantly impacted rheumatology practices for several years. CSRO played a pivotal role in leading a coalition of medical specialty and trade organizations to advocate for changes in Medicare policies that more accurately reflect the complexity of services provided by rheumatologists. This coalition’s efforts have resulted in CMS proposing important updates to the Medicare Claims Processing Manual, and incorporating elements of CSRO's recommendations to ensure that drug administration services are appropriately recognized and reimbursed. In a separate comment letter, the coalition urges CMS to finalize its proposals and to consider additional improvements that would address the “down coding” challenges that physician practices and infusion providers have faced.
In addition, CSRO has signed on to the Alliance of Specialty Medicine’s comment letter, addressing broader specialty concerns, including the continued decline in Medicare reimbursements and the need for CMS to work with Congress on a permanent solution to the long-standing issues with the PFS, among other issues of interest.
| |
|
September is Rheumatic Disease Awareness Month
Recognized each September, Rheumatic Disease Awareness Month was created to raise awareness for the over 52 million Americans living with a rheumatic disease. Often, advocacy is simply building awareness, and we invite you to join us on September 25 for a Day of Action to bring the issues impacting patients and practices to the attention of policy makers.
For our Day of Action, we will be providing the rheumatology community with a tool kit to easily join us in advocating by raising awareness. Additional details and reminders will be shared on social media and via email, so be sure to stay connected!
In the meantime, here are a few easy steps to get ready:
- Find us on X, LinkedIn, and Facebook to stay in the know
- Help spread the word by sharing what you see from CSRO on social media about RDAM throughout the month
- Schedule time in your day on September 25 to help take action
| |
Legislation Around the Country | |
|
CSRO Drives AFP Reform through LA Task Force
On Tuesday, August 20, CSRO Vice President of Advocacy & Government Affairs Madelaine Feldman, MD, FACR participated in a Louisiana Task Force meeting to assess the use of alternative funding programs (AFPs).
Dr. Feldman was one of 13 participants during the first meeting of this group, which was created after the Governor signed H.R.96 into law earlier this year. Given the Society’s initial advocacy on this resolution, CSRO secured an appointed position on this Task Force, which is chaired by the Commissioner of Insurance. Other participants included Joni Fontenot, RN, of the Rheumatology Nurses Society and Rheumatology Alliance of Louisiana, as well as representatives from the state pharmacy and medical society, health plans, AFL CIO, PhRMA and a patient advocate.
CSRO will continue to play an active role in this Task Force as it works to create a recommendation for the legislature’s consideration before the end of the year.
| |
|
CSRO Urges Newsom to Sign CA PBM Reform
The California state legislature has sent SB966, a PBM reform measure, to Governor Newsom’s desk for consideration. Throughout the legislative process, CSRO submitted comments in support of the measure, which would require that 100% of pharmaceutical rebates are passed through to the health plans.
The bill also includes PBM oversight, including reporting and licensure, as well as enforcement mechanisms to ensure compliance. CSRO believes PBM reform is critical towards ensuring that PBMs operate with greater transparency and accountability, thus contributing to a reduction in the overall cost of medications and improving patient care.
The Governor has 12 days after receiving the legislation to take action. CSRO has submitted comments and joined a sign on letter organized by the California Pharmacists Association encouraging the Governor’s signature.
| |
|
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: Sent to Governor’s desk
| |
Mark Your Calendar: Upcoming Events
| |
|
CSRO Fellows Conference: February 21-23, 2025
An annual event to help rheumatology fellows prepare for their future roles as practicing rheumatologists. Registration launching this fall.
| |
|
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.
| | | | |
