During a recent meeting convened by a Centers for Medicare and Medicaid Services (CMS) contractor, Acumen, LLC, Michael Schweitz, MD, FACR, raised concerns about a cost measure in development for rheumatoid arthritis (RA), spurred by feedback from practicing rheumatologists and their administrators during field testing. Representing CSRO, Dr. Schweitz explained that it is inappropriate to hold rheumatologists accountable for medication costs because they do not control the cost of rheumatologic drugs, nor do they have full access to the range of available therapies, including biosimilars, due to the perverse incentives associated with formulary construction, which is controlled by Part D prescription drug plans and their pharmacy benefit managers (PBMs). 

He also explained that rheumatologists are likely to be penalized for hospitalizations and other services that are not actually “clinically-related” to a beneficiary’s RA diagnosis. Instead, he pointed to the “over coding” phenomenon, where hospitals and health systems increase the number of diagnoses they include on claims in order to increase their risk score and negotiate higher payments from private plans, including Medicare Advantage. 

CSRO has long-raised concerns about the potential challenges with an RA cost measure, particularly if medication therapies are included, and will continue to urge CMS to delay implementation of such a measure if these concerns are not meaningfully addressed. CSRO will keep you updated as additional information is made available, including a recording of the web-based meeting.

On March 15, the Centers for Medicare and Medicaid Services (CMS) released its first implementation guidance related to the maximum fair price (MFP) provisions of the Inflation Reduction Act. This first guidance applies only to Part D medications that will be selected for the MFP process, because those will be subject to MFPs starting in 2026. The list of selected Part D drugs will be announced by September 1, 2023. Selected Part B medications will not be subject to MFPs until 2028, so CMS expressly states that selection and negotiation of Part B drugs are not addressed in this guidance and that the agency “will provide additional information in the future related to implementation for initial price applicability years 2027 and beyond.” CSRO will closely monitor regulatory activity to weigh in on the Part B drug selection and negotiation process, if needed.

In related news, CMS announced the first group of Part B medications that will be subject to inflationary rebates, also pursuant to the Inflation Reduction Act. These rebates, which will be deposited into the Medicare Trust Fund, will result in adjusted coinsurances on the affected medications. The list of medications subject to a rebate penalty will be updated quarterly; the first list can be found here.

An “advocacy win” can mean many different things. While having a bill signed into law is the ultimate win, there are many smaller wins that must take place before legislation is sent to a governor’s desk for signature. 

CSRO experienced one of those small wins this past month when Board Member Dr. Kostas Botsoglou hosted a virtual meeting with his New York State Senator, Patrick Gallivan. After meeting with Senator Gallivan, as part of CSRO’s Legislator Outreach Program, his office followed up to inform Dr. Botsoglou that he signed on as a co-sponsor of the Biomarker Coverage Bill (S.1196) – a bill that Dr. Botsoglou highlighted during their meeting.

This may not sound important, but Senator Gallivan’s signature made the bill a bi-partisan issue. His leadership role as the Senate Minority Whip also carries weight in helping garner support from his side of the aisle.

The outcome is a perfect example of why it is important for you to meet with your state elected officials. CSRO encourages the rheumatology community to partake in similar meetings within your state – our advocacy team can help with the details, making it easy for you to join a 15-minute virtual meeting. Email info@csro.info to express your interest.

CSRO is pleased to welcome Dr. Alex Oshmyansky, Founder and CEO of the Mark Cuban Cost Plus Drug Company, as the keynote speaker for our Advocacy Conference.

This flagship annual event brings the rheumatology community together to learn, network, and strategize about advocacy, and, exclusive for 2023, will feature a special celebration in honor of CSRO's 20 years of serving as a voice for rheumatology.

Registration is complimentary and open to all individuals who are currently working within or have retired from the field of rheumatology; sign up now to be a part of this noteworthy event.

2023 Advocacy Conference

August 25-27

Austin, TX

Earlier this month, CSRO welcomed rheumatology fellows from around the country to its annual Fellows Conference, providing the next generation of rheumatologists with practical career tips and insights not typically taught in academic training. Read about the Conference in recent highlights from Medscape:

• New Rheumatologists Need Insurance Awareness to Give Best Care (PDF available here)
• Rheumatology Fellows Learn About Career Opportunities (PDF available here)

More details on the conference presentations are available in our Education Library, including recordings from some of the sessions.

ICYMI: Opportunity For Action in Your State

The following states have active legislation that needs your support – make your voice heard today:

Colorado

Accumulator Programs

• Take Action: SB 195

Nebraska

White Bagging

• Take Action: LB 448

Nevada

Step Therapy

• Take Action: SB 194

Texas

Accumulator Programs

• Take Action: HB 999

Wisconsin

Accumulator Programs

• Take Action: SB100/AB103

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

Biomarker Testing

• SB 496: Set for hearing on 4/12

Gold Card

• SB 598: Set for Hearing on 4/12

COLORADO

Accumulators

• SB 195: Introduced – assigned to Health and Human Services committee

Step Therapy

• HB 1183: Passed the House, introduced in the Senate, assigned to Health and Human Services committee

KENTUCKY

Biomarker Testing

• HB 180: Signed by the Governor

MARYLAND

Biomarker Testing

• SB 805: Passed the House
• HB 1217: Passed the House

Step Therapy

• SB 515: Passed the Senate, favorable report by Finance committee
• HB 785: Passed the House, favorable report by Finance committee

MINNESOTA

Biomarker Testing

• HF 1978: Reported do pass as amended and re-referred to Health Finance and Policy committee

Non-medical Switching

• SF 328: Committee amends and reports do pass, re-referred to Health and Human Services

MISSOURI

Accumulators

• HB 442: Passed the House, introduced in the Senate

White Bagging

• HB 198: Public hearing held

MONTANA

Gold Card

• SB 380: Heard in House Business and Labor Committee

NEVADA

Rebate Pass Through

• AB 440: Introduced and referred to Commerce and Labor committee

NEW MEXICO

Accumulators

• SB 51: Passed the House, Senate concurs with House amendments

Biomarker Testing

• HB 73: Passed the Senate 

NORTH DAKOTA

Non-medical Switching & Prior Authorization

• SB 2389: House reported do pass

White Bagging

• SB 2378: Passed the House

OHIO

Biomarker Testing

• HB 24: Referred to Insurance committee

OKLAHOMA

Biomarker Testing

• SB 513: Referred to House Public Health committee

Rebate Pass Through

• HB 2853: Passed the House, introduced in the Senate and referred to Retirement and Insurance and Appropriations committees 

Step Therapy

• HB 1736: Referred to Retirement and Insurance committee

OREGON

Accumulators

• SB 565: Died – procedural deadlines not met

RHODE ISLAND

White Bagging

• H5680: Committee recommended measure be held for further study

TEXAS

Accumulators

• HB 999: Approved by Health Care Reform committee
• SB 1576: Referred to Health and Human Services committee

Biomarker Testing

• SB 989: Vote taken in committee
• HB 3188: Referred to Insurance committee

Rebate Pass Through

• HB 2180: Reported favorably by committee

White Bagging

• HB 1647: Left pending in committee 

Regional Town Halls: Mondays in April & May

Hear advocacy updates specific to your area and network with your community:

• April 3: FL, GA, NC, SC
• April 24: IA, KS, MN, MO, NE, ND, SD, WI
• April 24: AK, CA, HI, OR, WA
• May 1: ME, MD, MA, NH, NJ, NY, PA, VA
• May 1: AL, AR, LA, MS
• May 8: IN, KY, MI, OH, TN, WV
• May 8: AZ, NV, NM, TX

Business of Rheumatology: June 14, 2023

Save the date to join us for the next installment in CSRO's virtual seminar series to help support rheumatology practices in building and strengthening their business.

CSRO's Advocacy Conference: August 25-27, 2023

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

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.

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.