Our Issues
The CSRO is at the forefront of state, federal, and payer policies working to grant access, affordability, and relief for the rheumatology community. Our advocacy work focuses on educating members of Congress and state legislatures to achieve the mission of the CSRO: ensuring access to the highest quality care for the management of rheumatologic and musculoskeletal disease.
CSRO Advocacy Priority Issues:
- 340B Drug Pricing Program – The 340B drug discount program would benefit from realigning the program’s mission by placing the patient first and by establishing greater transparency and accountability to ensure the program’s success.
- Accumulator Adjustment, Alternative Funding & Maximizer Programs – Copay assistance is the only means many patients have to afford medically necessary medications. New policies being implemented by PBMs and plans are threatening co-pay assistance programs, and patients’ ability to afford their medically necessary treatments. CSRO supports legislation that prohibits the use of these programs.
- Biomarker Testing Coverage – Rapid innovation is occurring for biomarker testing in the rheumatology space. CSRO is working to ensure these tools are accessible for rheumatologists to utilize in their practice.
- Down Coding – CSM has established articles that erroneously deem many rheumatology infusions as non-complex, rather than assigning complex CPT codes. CSRO leads efforts to address inappropriate down coding of these complex drug administration services.
- Non-Medical Switching – Switching a patient’s coverage without the consultation of the patient and their physicians is fundamentally irresponsible. CSRO supports protecting currently-stable patients from switching medications for non-medical reasons within a plan year.
- Pharmacy Benefit Manager (PBM) Reform – PBMs and their control over drug out-of-pocket costs have managed to go largely unregulated, allowing them to quietly influence drug prices, the amount patients pay for their prescriptions, and which drugs are available and accessible to the public. The CSRO is actively working to reform and regulate the harmful practices of PBMs.
- Physician Reimbursement – Unlike other healthcare providers, the Medicare Physician Fee Schedule (MPFS) does not receive annual payment updates based on an inflationary index. CSRO supports long-term, stable payment mechanisms that appropriately pay physicians for health outcomes.
- Prescription Drug Affordability Boards – State policymakers are considering the use of prescription drug affordability boards and other pricing reform mechanisms to control the cost of prescription drugs. These policies have the potential to disrupt access to provider administered drugs, and CSRO is working to minimize the disruptive potential of these policies.
- Prior Authorization/Gold Carding – This administrative burden distracts from the provision of high-quality care and costs health systems close to a billion dollars annually. CSRO lends its voice to conversations regarding ways to reduce the administrative burden imposed by excessive prior authorizations.
- SAD Exclusion List – CSM established criteria to determine whether a drug is “usually” self-administered, and therefore excluded from Part B coverage. CSRO leads efforts to modify the SAD Exclusion List criteria.
- Step Therapy/Fail First – Step therapy policies have become far too common and can significantly hinder the patient’s health. CSRO supports policies that establish commonsense reforms that prevent insurance companies from abusive step therapy practices that prevent patients from accessing the medications they need.
- Underwater Biosimilars – Physicians who administer biosimilar medications are reimbursed far less for the drug than it cost them to purchase it, putting them financially “underwater” for the clinical visit. CSRO is advocating at the federal level to address this reimbursement crisis, which has led to financial hardship on physician practices.
- White Bagging – Many rheumatology practices currently use the “buy and bill” method of acquisition for provider-administered drugs. Payers have begun to challenge this process through mandates such as “white-bagging,” which CSRO actively campaigns against.
CSRO has been at the forefront of some of the greatest policy advances for rheumatology providers and their patients. Through the active participation of CSRO leadership, member organizations, and the broader community, we make advocacy work:
- The CSRO facilitated the creation of both the National Organization of Rheumatology Managers (NORM) and the Alliance of Transparent and Affordable Prescriptions (ATAP). These two pivotal organizations have amplified the rheumatology voice with payers, CMS, and state lawmakers across the country.
- Step Therapy/Fail First state policies have been key to helping patients override unnecessary protocols to access the medication that would work best for them in a timely manner. Through our work with the State Access to Innovative Medicine (SAIM) Coalition, at least 36 states have passed legislation limiting step therapy protocols and improving access for patients.
- Payer policy revisions and mandates have increased exponentially in the last five years. CSRO has been successful in helping overturn non-medical switching practices and protecting current patients by having them grandfathered into the original coverage policy. These payer issues also include reimbursement changes in coding and changes to acquisition models that have a significant impact on our providers.
- CSRO leadership participates in numerous Hill meetings throughout the year, which includes a federal fly-in that is hosted by the CSRO for leadership and advocates from our member organizations. Federal meetings are also held with CMS, MedPAC, and individual MACs to discuss ongoing issues impacting the practice of rheumatology.
CSRO Advocacy Resources:
