Last week, the House Ways & Means Committee hinted that it may mark up legislation that would address some of CSRO’s concerns regarding the Medicare Physician Fee Schedule (MPFS). However, a markup on these bills has now been postponed due to continued disagreements over legislative language. This will likely delay any fix until after the November election. 

In September, CSRO joined a provider sign on letter to congressional Leadership urging them to adjust physician payments annually with an inflationary update. According to the proposed 2025 MPFS, physicians will face a 2.8% reduction. When adjusted for inflation, Medicare physician payments have declined by 29% from 2001-2024, according to the letter. While a complete fix appears unlikely, members of the GOP Doctors Caucus have hinted at a temporary fix to address declining reimbursements. 

Earlier this month, House Oversight and Accountability Chairman James Comer (R-Ky.) wrote to pharmacy benefit manager (PBM) executives accusing them of providing false testimony before the committee during a July hearing. Comer stated that during the hearing PBM executives contradicted findings by the committee and the Federal Trade Commission (FTC).

CVS offered a response, in which they committed to their previous statements on reducing prescription costs for patients. The letter challenges the accuracy and “analytical rigor” of the FTC’s PBM report. CVS denied claims regarding pharmacy steering and under reimbursement, among other points raised by the Chair.

Energy and Commerce Advances Telehealth Extension Bill with PBM Offsets

The House Energy and Commerce Committee unanimously advanced the Telehealth Modernization Act (H.R. 7623) on September 18. The legislation extends telehealth flexibilities, including those related to geographic and originating site restrictions, practitioners eligible to furnish telehealth services, telehealth services for federally qualified health centers and rural health clinics, and the furnishing of audio-only telehealth services, through December 31, 2026.

The bill is offset by provisions to reform the pharmacy benefit manager (PBM) industry. Notably, CSRO’s policy priorities are incorporated, including delinking PBM reimbursement from the list price of the drug and passing through rebates directly to the patient. It would also require PBMs to provide detailed annual reports on drug costs, rebates, and fees to Medicare Part D plan sponsors and the government, starting in 2027.

House Passes Legislation to Ban Spread Pricing in Medicaid

The House of Representatives passed the Accelerating Kids’ Access to Care Act (H.R. 4758) on September 17 by voice vote. The bill aims to improve access to care for children with complex medical conditions by simplifying out-of-state Medicaid screening and enrollment processes for pediatric care providers. It also includes provisions requiring pass-through pricing models, and prohibiting spread-pricing, for payment arrangements with pharmacy benefit managers under Medicaid. CSRO’s PBM policy priority on delinking is also included within this measure.

House Judiciary Panel Holds Hearing to Consider Role of PBMs

The House Judiciary Subcommittee on the Administrative State, Regulatory Reform, and Antitrust convened a hearing on September 11 to consider the role of pharmacy benefit managers (PBMs) in the health care industry. The panel explored a PBM's ability to control access to and pricing of pharmaceutical products. The potential benefits and drawbacks of vertical integration in the PBM industry were a focus of the discussion, with witnesses describing the balance between efficiency gains and the likelihood for anticompetitive conduct. Members questioned witnesses about the impact of the PBM business model on independent pharmacies, expressing concerns about patient access to care in areas of the nation that are disproportionately served by independent pharmacists. There was general agreement on the need for greater transparency across the pharmaceutical supply chain, with witnesses recommending lawmakers consider requirements around transfer pricing and the publishing of true net pricing benchmarks.

In a recent op-ed, Dr. Madelaine Feldman, CSRO’s Vice President for Advocacy and Government Affairs, underscored the severe impact of prior authorization on patient care. Prior authorization, designed to control costs, has become a significant barrier for patients with autoimmune diseases like rheumatoid arthritis and lupus, leading to harmful delays in treatment.

CSRO has been at the forefront of advocating for reforms and is a strong supporter of the Improving Seniors’ Timely Access to Care Act—a bipartisan bill that would streamline prior authorizations within Medicare Advantage.

In a letter to Department of Health and Human Services (HHS) Secretary Xavier Becerra, CSRO, along with more than 40 physician, patient, and provider organizations, recommended reforms to the Self-Administered Drug (SAD) Exclusion List criteria. For background, medications on the “SAD List” are statutorily excluded from Medicare Part B coverage, but CMS has some discretion in determining which drugs are added to the list.

CSRO and its coalition partners argue that CMS’ criteria must be revised so that beneficiaries can access physician-administered drugs on the SAD list when disabilities or other conditions prevent them from self-administering these medications.

CSRO joined the Alliance of Specialty Medicine in expressing concerns about the CY 2025 Medicare Physician Fee Schedule (PFS), which proposes a 2.8% reduction in the conversion factor effective January 1. CSRO and the specialty coalition called on CMS to work with Congress on a permanent solution to the broken physician payment system, which has failed to keep pace with inflation over the last several years.

The coalition also endorsed CMS’ intent to make regular and consistent updates for direct and indirect practice expenses. In its own comments and in leading a coalition of physician and provider organizations, CSRO voiced support for proposed revisions to CMS’ program manuals that would better account for the complexity of non-chemotherapy drug administrations, aimed at addressing the broader issue of down-coding by Medicare Administrative Contractors (MACs).

CSRO and the coalition also urged CMS to take additional action to establish documentation guidelines and prohibit retroactive audits for certain complex drug administration services.

The Rheumatology Private Practice Alliance (RPPA) is a thriving community of over 1,100 rheumatologists from across the country, with more than 90% actively engaging in our Facebook Group. Their members are deeply committed to the sustainability of private practice, protecting physician autonomy, advocacy, and consistently delivering top-tier care to their patients.

RPPA's highly anticipated 2024 Growth Summit will be this October 18-20 in Houston at the Hyatt Regency Houston/Galleria. This in-person event is designed to foster meaningful connections, encourage collaboration, and offer mentorship opportunities to help private practice physicians excel.

The summit agenda is packed with actionable, high-impact sessions tailored to strengthen practice operations and offer real-world solutions. The summit is almost sold-out. To register, click the button below and use code CSRO100 for $100 off. Registration is free for fellows and those graduating in 2024.

Questions? Email Karleen Su, MD at event@rppa.co.

Do you have an event or opportunity you'd like to share? Email info@csro.info.

September is Rheumatic Disease Awareness Month

Building awareness is advocacy, and advocacy has been the cornerstone of CSRO’s mission since our founding. In honor of Rheumatic Disease Awareness Month, we are calling on you to join us for a Day of Action on September 25.

A patient's access to care, disease management options and overall quality of life are directly impacted by policy, and one of the easiest ways to make a positive impact is to create awareness among policy makers of the utilization management issues affecting the rheumatology community.

Next week, we will be sharing a tool kit to easily join us in advocating by raising awareness. 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

CSRO Continues to Educate on Harms of State PDABs

CSRO continues to voice its concerns regarding the unintended consequences of state Prescription Drug Affordability Boards (PDABs) that set upper payment limits (UPL). CSRO fears these proposals may drive up the cost of physician administered medications instead of making them more affordable for patients as the Board intends, while simultaneously causing significant financial strain on physician practices.

In September, CSRO Board Member Harry Gewanter, MD, FAAP, MACR met with Virginia House Delegate Karrie Delaney (D-09) to discuss her sponsorship of the state’s PDAB legislation. Dr. Gewanter highlighted the limited influence that existing PDABs have had in addressing out-of-pocket patient costs. He also explained that imposing a UPL on infusion medications will negatively impact physician practices and patient access to needed medications. CSRO appreciates Dr. Gewanter’s continued engagement with the Virginia state legislature on this important issue.

CSRO submitted comments in August to the Maryland PDAB regarding serious concerns over their plan to implement a UPL. In September, the PDAB approved the proposed plan, which now heads to the legislature for consideration. The Board cannot be granted UPL authority without legislative approval. CSRO will continue to express serious concerns over the UPL’s impact on physician reimbursement and patient access.

In Colorado, the state PDAB still has a number of open positions on the Advisory Board, which the PDAB is encouraged to consult on all pricing matters. If you are a Colorado resident and are interested in applying to represent providers and patients on this Board, click here to review the application.

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.

Rheumatic Disease Awareness Month: September

Help create awareness about how rheumatology patients suffer because they are not protected from utilization management practices.

CSRO Advocacy Conference: September 20-22, 2024

Gather with others in the rheumatology community in Nashville for CSRO's annual Advocacy Conference! 

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.

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.