On July 10, the Centers for Medicare and Medicaid Services (CMS) released the CY 2025 MPFS Proposed Rule, which includes a proposed PFS conversion factor of $32.36 starting January 1, 2025. The 2.8% reduction stems from the 0.00% update adjustment factor as established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the expiration of the 2.93% increase provided by Congress for CY 2024 in the Consolidated Appropriations Act, 2024, and a budget neutrality adjustment of 0.05% stemming from CMS’ proposals.

Down Coding

CSRO has been at the forefront of addressing problematic “down coding” of complex drug administration services, where Medicare Administrative Contractors (MACs) have educated rheumatology practices to use therapeutic administration service codes when they administer non-chemotherapy drugs. CSRO secured assistance from CMS in the form of a “Technical Direction Letter” (TDL) that directed the MACs to “pause” down coding, the release of Transmittal 12397 that made the substance of the August 2022 TDL publicly available, and the inclusion of a Request for Information (RFI) in the CY 2024 PFS proposed rule.

Following stakeholder feedback, CMS has proposed updates to its Medicare Claims Processing Manual, Chapter 12, section 30.5, to include language currently consistent with CPT code definitions for the complex non-chemotherapy infusion code series stating that the administration of infusion for particular kinds of drugs and biologics can be considered complex and may be appropriately reported using the chemotherapy administration CPT codes 96401-96549, noting that these services do involve serious patient risk which requires frequent consults with a physician or other qualified healthcare professional.

According to CMS, the proposed updates to the Manual will provide complex clinical characteristics for the MACs to consider as criteria when determining payment of claims for these services, including the need for staff with advanced practice training and competency, such as, a physician or other qualified health care professional to monitor the patient during these infusions due to the incidence of severe adverse reactions, and special considerations for preparation, dosage, or disposal for these infusion drugs. CSRO will provide CMS feedback on this proposal. 

RA Cost Measure

Despite the “do not recommend” vote from the Pre-Rulemaking Measure Review (PRMR) Clinician Committee Recommendation Group, CMS proposes to adopt a Rheumatoid Arthritis (RA) Cost Measure for use in the Merit-Based Incentive Payment System (MIPS) program.

During the development and testing of this cost measure, CSRO raised significant concerns based on feedback from private practice rheumatologists and their administrators. CSRO told CMS and it’s contractor that it was 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). 

CSRO also explained that rheumatologists could be inappropriately penalized for hospitalizations and other services that are not actually “clinically-related” to a beneficiary’s RA diagnosis, pointing 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 will continue to advocate against the inclusion of this cost measure in MIPS until these concerns are meaningfully addressed.

As shared in our last Bi-Weekly Update, CSRO and the National Community Pharmacists Association (NCPA) hosted a congressional briefing in Washington, DC on July 10 to highlight the need for PBM reform this year.

The event featured remarks from Representatives Buddy Carter (R-GA) and Nanette Barragán (D-CA), as well as a panel discussion moderated by CSRO's Vice President of Advocacy & Government Affairs Dr. Madelaine Feldman. The panel included:

• Steve Moore, PharmD, NCPA
• Antonio Ciaccia, 3 Axis Advisors
• Alex Oshmyansky, Cost Plus Drug Company
• Amy L. Hinojosa, MANA, A National Latina Organization

In her remarks, Dr. Feldman explained that “PBMs have eroded the doctor-patient relationship…It’s clear that PBMs are increasing out-of-pocket costs for patients and lining their pockets at the expense of patients, employers, and yes, the government.” Hear more from Dr. Feldman and her fellow stakeholders by watching the briefing recording here.

On July 23, the House Committee on Oversight and Accountability convened the third in its series of hearings on the role of pharmacy benefit managers (PBMs) in the prescription drug market. During the hearing, panel members heard testimony from the leaders of the nation’s three largest PBMs: CVS Caremark, Express Scripts, and OptumRx. The witnesses testified that PBMs play a “critical role” in the U.S. health care system.

They frequently placed the blame on drug manufacturers for the rising cost of prescription drugs, and asserted that PBMs only act to implement the benefit design choices selected by their clients – including pharmacy network size, preferred providers, and patient cost sharing. During the contentious hearing, lawmakers repeatedly pressured the witnesses to refute findings from the Federal Trade Commission, The New York Times, and state attorneys general that PBMs inflate drug costs, steer patients to affiliated pharmacies, and engage in anticompetitive behavior.

Committee members also discussed the impact of PBMs’ vertical integration with health insurers and pharmacies, questioning witnesses about the total revenue of parent companies CVS Health, Cigna Group, and UnitedHealth. The hearing was notable for the widespread bipartisan agreement on the need to increase transparency and accountability in the PBM market. 

Ahead of the hearing, the Committee released a congressional report on PBMs’ pricing tactics and impact on rising health care costs. The report, based on the panel’s review of more than 140,000 pages of documents and communications, highlights the following key findings: 

• The three largest PBMs have used their position to enact anticompetitive policies and protect their own profit margins, costing taxpayers and reducing patient choice. 
• Despite frequently touting the savings they provide, evidence indicates that PBMs often actually increase costs for patients and payers.
• By forcing drug manufacturers to pay rebates in exchange for favorable formulary tier placement, PBMs make it difficult for lower-priced competition to get on formularies. 
• The three largest PBMs have begun creating foreign corporate entities and moving certain operations abroad to avoid transparency and proposed state and federal government reforms.
• The use of tools such as prior authorization, fail first, and formulary manipulation by PBMs has detrimental impacts on Americans’ health outcomes.

CSRO continues to monitor this situation and will provide updates as appropriate.

CSRO joined the Community Oncology Alliance (COA), The Food Industry Association (FMI), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA) in sponsoring an ad that went into the Wall Street Journal on July 23 to conecide with the PBM executives testifying before the House Oversight Commitee referenced above.

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

Log in on Wednesday, July 31, to explore if larger groups, including super groups, are the way forward to maintain private practice in rheumatology through a panel discussion of representatives from Arizona Arthritis and Rheumatology Associates, Articularis Healthcare, Bendcare, and United Rheumatology/Specialty Networks.

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.

New Hampshire

Rebate Pass Through

• SB 555: Conference committee substitute adopted and enrolled

Rhode Island

White Bagging

• S2086: Signed by the Governor

Business of Rheumatology: July 31, 2024

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

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.

State Society Meeting Spotlight:

CSRO had a significant presence at the Florida Society of Rheumatology (FSR) annual meeting in Orlando, Florida earlier this month. With more than 300 rheumatologists in attendance over the three-day conference, the event served as a valuable platform for interactions and discussions on key issues in state, federal, and payer policies.

CSRO staffed a booth in the exhibit hall, where Fellow-at-Large Dr. Elnaz Balashi (pictured left) engaged with attendees. Dr. Balashi shared insights on the advocacy and educational initiatives offered by the CSRO to the rheumatology community. Of particular note was the promotion of the upcoming CSRO Advocacy Conference in Nashville, where member societies can send two representatives for free. CSRO also provided an informative update to FSR members during their business meeting, covering a range of topics, including updates on federal and state policies relevant to rheumatology. CSRO was glad to connect with FSR and engage with its members!

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.