From abortion access to Medicare drug costs: How politics impacted rheumatology in 2024

For better or worse, many of health care’s most important challenges today seem to stem from — and could potentially be solved through — politics.

Where those challenges impact rheumatologists, Healio Rheumatology is there to shine a light.

The frustrations of prior authorization remained a top concern in 2024, while CMS also cut the Medicare Physician Fee Schedule conversion factor for the fifth year in a row, further tightening the screws on physicians’ finances.

The American College of Rheumatology banged its drum about both issues throughout the year, declaring at a hearing on Capitol Hill that the latter “must be the top priority of Congress.” The organization also moved the ball forward on boosting inadequate Medicare reimbursements for biosimilars and celebrated a “huge win” for rheumatology patients with a court ruling on copay assistance programs.

For deeper dives into all this and more, check out this year’s coverage of the politics of medicine below.

CMS finalizes rule streamlining, digitizing prior authorization process

CMS has finalized a new final rule that aims to shorten prior authorization timelines and streamline processes to remove barriers to patient care, according to a press release.

The rule will require prior authorization decisions to be sent within 72 hours for urgent requests, or 7 days for standard requests, according to the release from CMS. Denials will require a specific reason, and payers must report certain prior authorization metrics on their website. Read more.

Legislation seeks to minimize prior authorizations that ‘deny, delay and aggravate’

Attempts to curtail prior authorizations for patients insured by Medicare Advantage plans have failed in back-to-back legislative sessions in 2019 and 2021, but a new bill has some experts hopeful that the third time is a charm.

“The previous bill had a $16 billion price tag from the Congressional Budget Office,” Robert W. Levin, MD, past president of the Florida Society of Rheumatology, president of the Alliance for Transparent and Affordable Prescriptions, and associate affiliate professor of medicine at the University of South Florida, told Healio. “The way the new bill is written now, the score is budget neutral. Regardless of whether it has more merit or not, that means this bill has a fighting chance.” Read more.

VIDEO: Medicare physician fee schedule ‘on an untenable track’

In this video exclusive, Robert W. Levin, MD, president of the Alliance for Transparent and Affordable Prescriptions, championed the American College of Rheumatology’s recent advocacy for an improved Medicare fee schedule.

“I think we all know that we have seen declining reimbursements, especially in the last few years,” Levin told Healio during the Congress of Clinical Rheumatology East. “It’s really just going on an untenable track.” Read more.

White House decision not to appeal copay ruling a ‘huge win’ for rheumatology patients

A recent legal battle over copay assistance programs for biologic medications, and whether they must count toward insurance deductibles, have resulted in a positive outcome for patients, according to the American College of Rheumatology.

In early 2023, the ACR raised concerns with CMS about its policy of allowing insurers to exclude copay assistance programs from counting toward a patient’s deductible. Advocates for the ACR argued that many rheumatology patients require copay assistance to maintain quality of life on treatments that are necessary to their physical and mental well-being. Read more.

US Supreme Court decision on mifepristone ‘not a victory, but a punt’

On June 13, the U.S. Supreme Court rejected a lawsuit that challenged the FDA’s approach to regulating the abortion pill mifepristone.

Although some viewed it as a win for reproductive rights and the larger medical community — including rheumatologists and their patients — some experts believe further legal challenges await. Read more.

ACR urges congressional leaders to reform ‘underwater’ biosimilar reimbursement

The American College of Rheumatology has joined a coalition of more than 40 other organizations calling on congressional leaders to address what they see as insufficient Medicare reimbursements for biosimilars.

The group, which also includes the Arthritis Foundation and dozens of state and local rheumatology organizations, have dubbed themselves the Underwater Biosimilars Coalition. On Nov. 30, the coalition sent a letter to leaders in both the U.S. House of Representatives and the Senate expressing “grave concerns” about providers being reimbursed for less than they spend to administer some biosimilars in outpatient facilities under Medicare Part B, leaving them “underwater.” Read more.

Enbrel, Stelara to be discounted nearly 70% through Medicare price negotiations

The list prices of Stelara and Enbrel for Medicare users will be discounted nearly 70% come 2026 as a result of the first round CMS price negotiations with drugmakers, the White House has announced.

Beginning Jan. 1, 2026, a 30-day supply of Stelara (ustekinumab, Janssen) will be discounted 66% from its 2023 list price, from $13, 836 to $4,695. Meanwhile, a 30-day supply of Enbrel (etanercept, Amgen) will be discounted 67%, from $7,106 to $2,355. Read more.

ACR calls for ‘appropriate reimbursement’ from CMS after proposed 5th year of cuts

The American College of Rheumatology has submitted comments to CMS on proposed cuts to physician payments, warning of worsened burnout and staff shortages, and calling for “appropriate reimbursement,” according to a press release.

CMS recently proposed a fifth consecutive year of cuts to the Physician Fee Schedule, reducing physician payments 2.93% and cutting $0.93 from the current conversion factor in 2025. Read more.