Most rheumatology providers are familiar with the following frustrating scenario: After spending months or even years working to stabilize a patient’s autoimmune disease and find a therapy that really works well for them, they run into the problem of figuring out how the patient is going to be able to afford their medication. We are encouraged by President Biden’s acknowledgement of these challenges in his State of the Union speech. By reiterating his call to lawmakers to rein in high drug prices, President Biden is taking a strong stand on the behalf of the more than 54 million Americans living with a rheumatic disease.
Even with good insurance coverage, astronomical drug prices make it hard for many of our patients to afford treatment. In 2019, a survey the American College of Rheumatology (ACR) conducted of people living with a rheumatic disease found the median annual out-of-pocket treatment cost for patients to be $475. A year later, a subsequent patient survey found that reported out-of-pocket costs had more than doubled – to $1,000 per year. More than a quarter of patients paid over $2,000 per year out of pocket.
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High drug prices are also a major contributor to rising insurance premiums, cost-sharing and deductibles. This additional financial burden has been associated with an increase in patients delaying care, abandoning or forgoing treatment entirely – which risks flare-ups, disease regression, permanent disability, and even pre-mature death.
The bottom line is that high drug prices directly harm our patients. It is therefore incumbent upon all providers to continue advocating for reforms that will bring these costs under control.The ACR’s 2022 Health Policy Statements articulate a range of potential solutions that would meaningfully reduce drug costs for patients and decrease associated barriers to treatment access.
First, the ACR supports policies that limit patient out-of-pocket costs. The Build Back Better Act proposes a cap on monthly cost-sharing payments for Medicare Part D beneficiaries as well as an annual cap on all out-of-pocket drug costs. These policies would go a long way to ensuring those who need specialty medications are able to afford them.
Second, policymakers must rein in Pharmacy Benefit Managers (PBMs) whose practices inflate drug list prices and stick patients with higher copays and cost sharing –creating unnecessary and progressive barriers to access treatment in the first place. As the middlemen who work on the behalf of insurers, PBMs make additional profits off the savings they’re supposed to pass on to patients. The insurers who contract with – and often own – PBMs then turn around and throw up access barriers in the form of prior authorization and step therapy requirements.
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Nearly half of the 2020 survey respondents reported needing prior authorization to access treatment or have been forced to try medications other than ones prescribed to them under mandated step therapy before they can receive the prescribed treatment. These practices, which put insurance company bureaucrats between patients and the treatments prescribed by their physician, have been linked to delayed care which leads to worse health outcomes.
Lastly, policymakers should allow Medicare to negotiate drug prices with pharmaceutical companies. The United States is alone among developed democracies in its inability to negotiate prices directly with manufacturers. Absent generic or biosimilar competition, there is little incentive for manufacturers to lower prices over time, and in fact the rate of annual price increases has often far outpaced the rate of inflation.
To ensure that Medicare price negotiation creates real savings and increased access for our patients, it must be implemented in a way that reduces the actual prices of the drugs, rather than simply reducing reimbursement to the providers who administer them to patients. Past proposals, such as the Trump Administration’s Most Favored Nation model, would have significantly cut reimbursements to specialists who administer Part B therapies in the hopes that it would motivate manufacturers to voluntarily lower prices – consequently restricting patient access to treatment while doing little to address the root cause of high prices.
Likewise, the most recent proposal to make its way through Congress as a part of the broader Build Back Better Act, also risked the unintended consequence of putting providers and their patients in the middle of the proposed negotiation between Medicare and drug manufacturers. In December, the ACR joined two other specialty associations in proposing a solution that would exempt Part B reimbursements from sequestration. We stand by that proposal as a solution that would protect our patients’ access to Part B treatments while bringing down costs for everyone.
As the specialty organization of rheumatology providers, the ACR has a responsibility to not only look after our patients’ medical needs, but to advocate to ensure they are able to access and afford their treatments. Our nation has highly innovative pharmaceutical interventions to help patients – it shouldn’t be cost prohibitive for anyone to get the treatments they deserve and so desperately need. Now is the time for Congress to answer President Biden’s call to action and pass meaningful drug pricing reform that addresses the artificially inflated cost of drugs by manufacturers, PBMs, and payer formulary relationships.
Photo: cagkansayin, Getty Images
Kenneth G. Saag, MD, MSc is Professor of Medicine and holds the Jane Knight Lowe Endowed Chair in the Division and the Department of Medicine, University of Alabama at Birmingham. He became Division Director of Clinical Immunology and Rheumatology in July of 2020. His research focuses on comparative effectiveness and safety of therapeutics as well methods to improve quality of care in gout and osteoporosis. He is Vice Chair of Outcomes and Effectiveness Research and is also the Director of the UAB Comprehensive Arthritis, Musculoskeletal, Bone, and Autoimmunity Center. He has been a practicing physician with UAB Medicine and researcher in the UAB School of Medicine since 1998.
Dr. Saag is President of the American College of Rheumatology and he is a past President of the National Osteoporosis Foundation Board of Trustees, the only rheumatologist to hold that position. He served UAB as Director, Center for Outcomes, Effectiveness Research and Education (COERE) from 2009 to 2020. He also directs the Center of Research Translation (CoRT) in Gout and Hyperuricemia, a program supported by the NIH for nearly a decade. He also founded and directed the UAB AHRQ funded Center for Education and Research on Musculoskeletal Disorders.
Trained as an engineer at the University of Michigan, he received his M.D. from Northwestern University and the M.Sc. in Epidemiology from the University of Iowa. As a Medical Resident at Evanston Hospital, he was recognized as Outstanding Intern of the Year and as a Chief Resident. He completed his fellowship in rheumatology at the University of Iowa. He served as an Assistant Professor at the University of Iowa under Francois Abboud before joining our Department under the leadership of Bill Koopman as Chair and Bob Kimberly as Division Director.
