Newswise — ATLANTA – In comments submitted to BlueCross BlueShield of Tennessee, medical societies representing rheumatology, ophthalmology, dermatology, gastroenterology and urology specialists joined the American College of Rheumatology (ACR) to raise grave concerns about a recent insurance trend that requires providers to obtain physician-administered treatments through mail-order specialty pharmacies. Providers are concerned the mandate adds an additional layer of red tape that will delay patient care, reduce the ability of providers to ensure therapies have been properly handled and safely stored, inflate patient out-of-pocket costs, and result in an increase of drug waste. 

“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,” said Ellen Gravallese, MD, President of the ACR. “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. 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.”

Under the current model of care, rheumatology providers secure in-office treatments at the lowest price possible through negotiating periodic bulk purchases directly from manufacturers and storing the medications in-house to make them readily available. Once needed, the treatments are administered under provider supervision to watch for adverse reactions due to their potency. The new policy proposed by BlueCross BlueShield would mandate patients and/or physicians obtain the treatments from the insurer’s preferred specialty pharmacies instead and wait for them to be shipped to the provider, so that the insurance company can take advantage of rebates negotiated by their pharmacy benefit manager (PBM).

PBMs are hired by insurers to manage their drug benefit programs and have been receiving increased national scrutiny that has reached the U.S. Supreme Court for their lack of transparency around rebates and where “cost-savings” are going while prescription drug prices, insurance premiums and out-of-pocket costs for patients continue to soar. The controversial role of PBMs and the lack of reduced out-of-pocket costs for patients were focal points of the ACR’s 2018 Rheumatic Disease Report Card.

Providers are concerned this new insurance practice will increase administrative burden due to one-off procurements through multiple specialty pharmacies and will reduce confidence that the medications have not been exposed to high temperatures. Additionally, remaining doses of the drug would have to be thrown away if a patient is unable to use the medication for any reason (i.e. infection, change in medical history or intolerance/ineffectiveness) due to it already being assigned to one individual.

The specialty groups also expressed concerns that many providers will not be able to take on the additional costs of greater administrative burden and reduced efficiency in prescribing, nor the liability around administering drugs for which they are unable to confirm the handling prior to reaching their office, thereby requiring patients to look for care in other treatment settings that carry higher out-of-pocket 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…” the letter states. “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.”

The letter goes on to share that some patients may lose access altogether, because not all hospital facilities accept medications from outside specialty pharmacies, and that any savings to insurers that were derived from PBMs negotiating drug prices for their specialty pharmacies would likely be offset by drug waste and higher point-of-care costs.

The comment letter was signed 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.

# # #

The American College of Rheumatology (ACR) is the nation's leading medical association for the rheumatology community and represents more than 7,700 U.S. rheumatologists and rheumatology health professionals. As an ethically driven, professional membership organization, the ACR is committed to improving healthcare for Americans living with rheumatic diseases and advocates for policies and reforms that will ensure safe, effective, affordable and accessible rheumatology care. For more information, visit