SAN FRANCISCO ― New rheumatologists face a wide range of significant challenges brought on by the increasing complexity of insurance billing and rapid changes to managed care practices, especially techniques of utilization management and pharmacy benefit managers (PBMs), speakers said at the 2023 Fellows Conference of the Coalition for State Rheumatology Organizations (CSRO).
“We are seeing the impact of the environment eroding the patient-doctor relationship,” CSRO President Gary Feldman, MD, told participants.
Michael Saitta, MD, MBA, a rheumatologist in Fayetteville, Arkansas, said fellows should learn more about health insurance in order to take better care of their patients and their practice. “Your training includes a variable level of discourse on the health insurance market,” he said. Health insurance today is a mess. Costs have exploded. “Is anybody really happy with the current system?”
Although the healthcare system is sometimes compared to a dumpster fire, he said, a plate of spaghetti, with its multiple interconnected pathways, might be a better metaphor for understanding all that’s happening in the healthcare system and, more importantly, how it might be fixed.
Madelaine Feldman, MD, a rheumatologist in private practice in New Orleans and CSRO’s vice president of advocacy and government affairs, is a frequent advocate in Congress, state legislatures, and elsewhere regarding the utilization management techniques used by managed care and PBMs and how these are negatively affecting the ability of rheumatology patients to get the treatments they need. Such techniques include the following:
Prior authorizations imposed by the health plan before a medication can be dispensed
Step therapy, which requires the patient to fail as many as three or four payer-preferred drugs before trying the one recommended by the rheumatologist
Nonmedical switching, in which a patient is forced to change medications for a nonmedical reason related to the PBM’s formulary
Accumulator adjustment programs, which increase the patient’s out-of-pocket and deductible commitments
“There is very little transparency in how the money flows with PBMs,” Madelaine Feldman said. “In reality, PBMs are able to make profits by the perverse incentive of putting higher-priced drugs on their formularies, thus increasing the amount of rebates paid to them, without sharing any of the benefit with patients.”
PBMs have resisted disclosing this information, saying it would inhibit competition and cause drug prices to go up. The key thing to understand, she said, is that there is huge competition today to get preferred formulary placement. “Consequently, treatment choice for patients is not based on doctor-patient shared decision-making but on the highest rebate promised to the PBM,” she said.
“A rheumatology fellow recently told me that his patients will sometimes blame him for the lack of choice and high prices of the medications,” Madelaine Feldman related. What she has started to do with patients, after discussing all the available drugs appropriate to their condition, is to ask: “What is your insurance? The reason I’m asking is that we can come up with a game plan, but the entity that will determine what you will receive is the insurance company.”
What does Madelaine Feldman want fellows to take away from the CSRO conference? “I hope to arouse their anger, initially, which then works its way into a passion to change the system. We’re all so busy. Sometimes it takes lighting a fire under people,” she said.
CSRO has an online action center to facilitate sending letters to legislators, as well as a map tool for looking up any active legislation in their state. “Spread the word to your peers. Use your voice to help pass PBM reforms. Tell other fellows to come to the next CSRO fellows meeting,” she said.
“We got into this space because a few community rheumatologists were angry over decisions about how drug infusions would be paid for,” she said. “A group went to Washington, to Congress and Medicare, and changed the policy,” Madelaine Feldman said. A few passionate people really can make a difference. “Join the action. We’re always looking for rheumatologists and their patients to testify on these issues.”
No relevant financial relationships were reported by the conference speakers.
Larry Beresford is a medical journalist based in Oakland, California, with specializations in hospice, palliative care, hospital medicine, and rheumatology and has contributed to a number of Medscape and MDedge publications.
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