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Rheumatologists Say States Can Improve Care, Starting With PBMs, Access

Allison Inserro
How easy is it to live with rheumatic disease across the country? Citing the expense of medications and various other factors, a state-by-state report card aimed at stimulating advocacy efforts says not very well, according to the American College of Rheumatology.
How easy is it to live with rheumatic disease across the country? Citing the expense of medications and various other factors, a state-by-state report card aimed at stimulating advocacy efforts says not very well, according to the American College of Rheumatology (ACR).

The Rheumatic Disease Report Card rates all 50 states and the District of Columbia, assigning letter grades according to their progress in the areas of access, affordability, and the promotion of active lifestyle habits.

Overall, the average state grade was a “C,” while Maryland earned an A. Oklahoma and Alabama scored a D, the 2 lowest grades in the report.

No state earned an A in the area of affordability, although 3 states received B grades: Alaska, New York, and Maryland.
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The ACR cited the practice of pharmacy benefit managers (PBMs) and the related rebates, fees, and co-pays that put prescription drugs, whether biologics or biosimilars, out of patient reach.

In an interview with The American Journal of Managed Care® (AJMC®), rheumatologist Kelly Weselman, MD, elaborated on the issues raised in the report.

Asked why the ACR focused on PBMs specifically, during a year when the Trump administration, for instance, has tried to make a point of publicly highlighting drug company pricing, Weselman replied that the report aims to look at what can be done about the cost of medication at the state level.

Noting that the issues are all “tied together,” Weselman, who is also chair of the ACR’s Communications and Marketing Committee, said, “we needed objective information, we needed something that could be affected at the policy level, at the state level. Fixing drug prices is not something that we can do at the state level.”

For instance, the report highlights legislative efforts in Arkansas, Florida, and New York, and laws in Maryland and Vermont barring higher coinsurance rates for specialty drugs.

In Ohio, the state recently told the PBMs managing its Medicaid contracts that starting in 2019, it would insist on transparent contracts.

The report does not mention the rising issue of co-pay accumulators, where drug coupons are kept from being applied towards insurance deductibles. Weselman said drafting the ACR report began earlier this year, but said co-pay accumulators are a definite concern, as they “are still tied to specialty tiers in PBMs, because it’s the PBMs that make the decision on the copay cards.” Some PBMs may not accept any co-pay cards at all, she said.

Like the specialists who vented their frustrations with PBMs and health insurers at last year’s ACR meeting, Weselman described what typically happens with her patients, whether they are on commercial or federal plans. She’ll go through the prior approval process, and the patient will find out what the co-pay is, whether the co-pay card is allowed, and if medicine can be delivered.

For some patients, like one she saw this week, they are stuck in a backward merry-go-round trying to get medication approved. This particular patient has failed every medication for rheumatoid arthritis (RA), Weselman said, except for 2. Of 1 of the 2, she couldn’t afford the co-pay, and the co-pay card was not allowed. Of the other medicine, it cannot be approved because she hadn’t tried the other one first—the one she cannot afford.

“She's stuck in this Catch-22, she can’t get access to the medicine she has insurance for. This happens a lot. I have another patient in a similar situation—the pharmacy benefit manager won’t accept the co-pay card, and then the pharmaceutical company says they’ll reimburse her after the fact, but she doesn’t have enough money in the bank to pay thousands of dollars up front for the medicine to turn around and wait a few weeks for reimbursement,” said Weselman.

“These patients are young people, who are working, who have jobs, [and are] trying to function with swollen joints,” she said. One patient ruptured a tendon in her hand while waiting for approval for medicine and lost function in a finger, she said.

“That’s the kind of thing that shouldn’t happen in the United States,” Weselman said.

The report addressed step therapy—known as “fail first”—as another barrier, but Weselman said there is an additional issue that crops up when patients switch insurers. Since insurance companies have different step therapy programs, it becomes complicated when different step therapy programs take over. The patient might be stabilized on one medication, but when a new company takes over, a new process kicks in, requiring another appeal. There are no grandfather clauses. It also doesn’t make sense to force patients to retry and then fail medicines that they’ve already tried previously, she said.

About 1 in 4 adults have a diagnosed rheumatic disease, the report said, and rheumatic diseases generate about $140 billion in medical costs annually.

The report also delved into issues pertaining to the rheumatolgy workforce, the uninsured rate, and states where adults with rheumatoid disease are the most able to keep up with a healthy, active lifestyle to help mitigate the effects of disease.

Although more drugs for RA are on the horizon for approval for 2019 and beyond, Weselman is not overly optimistic that patients will see relief, “given the complicated environment for drug pricing.”

“I’d like to think that the more medications, the better it’ll drive down pricing, but that’s not what we’ve seen for the last decade,” she said.

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