The American College of Rheumatology this week joined seven other medical societies representing specialists in ophthalmology, dermatology, gastroenterology and urology in warning BlueCross BlueShield against a recent insurance trend that requires providers to obtain physician-administered drugs through mail-order specialty pharmacies.
In a letter to BlueCross BlueShield of Tennessee, the organizations argued that the mail-order mandate adds additional layers of bureaucracy that will delay necessary care, increase costs for patients, increase drug waste, and reduce the ability of providers to ensure that therapies have been properly handled and safely stored.
“We have had an alarming number of practices reporting they have been denied the ability to use therapies currently available in their offices to administer patient care quickly,” ACR President Ellen Gravallese, MD, said in a press release. “Rheumatology patients receiving in-office treatments typically have debilitating conditions such as rheumatoid arthritis that cause severe pain, inflammation, joint immobility and deformity.”
“The decision to use a more potent infusion or injection therapy often comes after patients have failed less potent prescription drugs and have continued to show signs of disease activity and/or progression,” she added. “Finding an effective treatment quickly is imperative, because joint damage progresses in the setting of continued inflammation, and we cannot reverse damage once it has already taken place.”
The ACR this week joined seven other medical societies representing specialists in ophthalmology, dermatology, gastroenterology and urology in warning BlueCross BlueShield against a recent insurance trend that requires providers to obtain physician-administered drugs through mail-order specialty pharmacies.
According to the ACR, the new policy proposed by BlueCross BlueShield would change the current system — in which providers negotiate bulk drug purchases from manufacturers and store them in-house where they are readily available — to require that patients and physicians instead obtain treatments from the insurer’s preferred specialty pharmacies. This would force physicians and patients to wait for these treatments to be shipped to the provider, but would allow the insurance company to take advantage of the rebates negotiated by their pharmacy benefit manager, the ACR added.
The ACR has previously criticized the role of pharmacy benefit managers in drug pricing and availability, stating that there is a lack of transparency regarding rebates and where the resulting cost savings have gone down as costs and premiums continue to increase.
According to the ACR, providers are concerned that the new policy will increase administrative burden by mandating one-off procurements through multiple specialty pharmacies, with many worried about the drugs being exposed to high temperatures. In addition, remaining doses will have to be disposed of if a patient is unable to use the medication for any reason, increasing waste, the organization said.
The letter, cosigned by the American Academy of Ophthalmology, American Academy of Dermatology, American Gastroenterological Association, American Urological Association, Coalition of State Rheumatology Organizations, Alabama Society for Rheumatic Diseases and Tennessee Rheumatology Society, goes on to state that the new policy may lead some patients to lose access to these drugs altogether. They argue that not all hospital facilities accept medications from outside specialty pharmacies, and that any savings to insurers that were the result of pharmacy benefit managers negotiating drug prices for their specialty pharmacies would likely be offset by drug waste and higher point-of-care costs.
“The predictable result of this policy will be a shift in site of care for your patients’ infusions to a more expensive hospital outpatient setting, which may serve as a significant barrier to their access,” read the letter, in part. “Not only will treatment costs be higher in the hospital setting, but there will be a predictable minority of patients who due to their inconvenience, the higher out-of-pocket cost, or simply fear of the unknown, will drop their treatments when transferred to this setting, and their overall healthcare costs will predictably rise as their diseases flare.”
BlueCross BlueShield issued a statement in response, asserting that “we’re not denying treatments and we’re not asking members to seek care from different doctors or at different facilities.”
Disputing several of the claims made in the letter, BlueCross BlueShield noted that rather than driving higher costs for patients, “this program will help Tennessee employers save around 20% on provider-administered specialty drugs in 2020. Those savings go directly to the employers and the members covered by their plans — not BlueCross or a [pharmacy benefit manager].”
Regarding the potential wait time for the shipment of drugs to the provider, the insurer responded that “our specialty pharmacies can deliver drugs anywhere in the United States in 24 hours, so ordering through them should not be a barrier to care under normal circumstances.” BlueCross BlueShield did acknowledge “rare cases” in which treatments were prescribed and administered same-day, and were developing an “exception process” to streamline this aspect.
BlueCross BlueShield also emphasized that, despite concerns that rebates would play a larger role in this program, “We negotiate the prices directly with our in-network specialty pharmacies, and that network is managed directly by us at BlueCross. Our pharmacy benefit manager is not involved in setting these prices.” – by Jason Laday