New ACR president: Pharmacy benefit managers, artificial intelligence ‘must be regulated’
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Although artificial intelligence presents “exciting opportunities,” its use in patient care “must be regulated” to address biases in decision making, said newly appointed American College of Rheumatology President Carol Langford, MD, MHS.
“The interpretation of AI-provided data needs to be made in the context of each patient’s history, clinical presentation, social factors and preferences,” Langford told Healio. “AI interpretations should not limit access to care. We also support strict guidelines on AI program development, with attention paid to maintaining patient confidentiality and privacy.”
Langford, who assumed her new role as 88th ACR president in November, is director of the Center for Vasculitis Care and Research, in the department of rheumatic and immunologic diseases, at the Cleveland Clinic, where she is also the Harold C. Schott endowed chair in rheumatic and immunologic diseases. She is additionally a professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine.
In a wide-ranging interview with Healio, Langford said she believes the future of rheumatology is “bright,” but not without serious challenges. Among these challenges, according to Langford, is the role of pharmacy benefit managers (PBMs) play in the U.S. health care and prescription drug system.
Reforming PBMs’ activity and their role in deciding which drugs patients have access to will remain a priority for the ACR, she said.
“Unfortunately, congressional action is necessary to correct this dysfunction in the marketplace,” Langford said. “Patients are making sacrifices to afford their medication, are unable to get approval for the drugs prescribed by their doctor, and often have to modify the use of their medication or skip doses because of barriers to accessing their medications.”
To discuss these and other pressing topics in rheumatology, Healio sat down with Langford for a Q&A.
Healio: What are your top priorities for your tenure as ACR president?
Langford: The mission of the ACR is to empower rheumatology professionals to excel in their specialty. During this year, I plan to focus on three areas.
Education is fundamental to career growth and gaining new knowledge that benefits patients. My first goal is to highlight the many ways ACR provides rheumatologists and rheumatology professionals with the ability to engage in education that fits the way they wish to learn.
The catalyst of that new information is research. In my second goal, I aim to emphasize how the ACR is there to support investigators in conducting their research, presenting their findings at ACR Convergence, and publishing through our journals.
Finally, my third goal is to enhance connections between the ACR and our rheumatology community so that every member sees their goals reflected and supported through its mission.
Healio: How did you first begin your journey in rheumatology and the ACR?
Langford: My interest in medicine began at a young age, and throughout college and medical school research was an integral part of my academic life. During residency, I became interested in rheumatology upon seeing the opportunities to conduct research and provide patient care.
I joined the ACR in 1993, and at my very first annual meeting, I realized this was an organization I wanted to be a part of. My first volunteer role was in 1995, doing abstract reviews, after which I gradually became involved in committee work. Over the last 3 decades with the College, I served as clinical abstract chair for the annual Convergence and chaired or co-chaired the committees on education, finance, membership and awards, all of which have been fulfilling.
I was also an associate editor for Arthritis & Rheumatology, one of the ACR’s premier, peer-reviewed rheumatology journals. For the past 3 years, I have served on the ACR’s executive committee as treasurer, president-elect, and now as president for the 2024-2025 years.
Healio: Let’s dig into some deeper topics. Could you talk about the legislative and regulatory push to reform PBMS?
Langford: Because of misaligned incentives under current law, the largest PBMs reportedly engage in business practices that drive up prescription drug costs rather than lower them for patients. The fact that three PBMs process more than 80% of prescription drug claims in the United States, giving them immense market power, makes it very challenging for employers to negotiate contract terms to make medication affordable for workers and families.
This skewed market drives up drug costs for employers, patients and taxpayers, which is why the ACR supports policy changes that help our patients access their treatments more affordably by reducing the impact of PBMs.
Healio: What are some of the details of those policy changes?
Langford: The ACR supports increased transparency and accountability for PBMs. This includes revealing PBM business arrangements and financial incentives, so stakeholders can better understand where the billions of dollars drawn from the system and into the PBMs come from.
The ACR supports banning spread pricing and requiring 100% pass-through of discounts, fees and other payments from drug manufacturers to plan sponsors and patients. The ACR also supports measures that would delink PBM fees from the list price of a medicine, and instead tie PBM payments to the services they provide. This would eliminate incentives for PBMs to favor higher-priced drugs, which make them more money through rebates and fees, over lower-cost alternatives that save patients money.
These changes are imperative to ensure a free market operates as intended, without steering plans and patients toward higher-priced medications and making health care unaffordable.
Healio: What are some of the obstacles to accomplishing these objectives in terms of PBM reform?
Langford: Unfortunately, congressional action is necessary to correct this dysfunction in the marketplace. Patients are making sacrifices to afford their medication, are unable to get approval for the drugs prescribed by their doctor, and often have to modify the use of their medication or skip doses because of barriers to accessing their medications.
Each day that passes without PBM reform is another day when drug costs erode access to affordable health care, so we would love to see this Congress include reform in the health care package they are working on. Otherwise, the ACR is prepared to hit the ground running with the next Congress to reform PBM practices that hinder patient care.
Healio: How do you plan to improve racial and gender equity within rheumatology?
Langford: When we consider equity in rheumatology, including racial and gender gaps, we also consider patient care and issues affecting rheumatology professionals.
The ACR has numerous initiatives focused on health equity and promoting a positive social impact through programs that educate rural practitioners and primary care physicians on rheumatic disease disparities. We also engage with medical students from programs at minority-serving institutions that don’t have rheumatology curricula, to increase awareness and consideration of the specialty as a career and address underrepresentation in rheumatology.
Regarding gender equity, we recognize that the field of rheumatology is constantly evolving. The greater percentage — more than 60% — of rheumatology fellows are female. That is why we are committed to increasing our understanding of the current landscape and issues at play, whether a female rheumatologist is in private practice or academia, or is a clinician, researcher or educator, and whether she is practicing in a rural area or a major metropolitan city, no matter the stage of her career.
Earlier this year, immediate past president Deborah Dyett Desir, MD, launched the women in rheumatology task force to help us identify and respond to gender equity gaps affecting our members.
Healio: A quick glance at the ACR Convergence 2024 program reveals a lot of interest and discussion surrounding AI and machine learning. How do you think these technological advances are going to impact the specialty?
Langford: AI tools will undoubtedly influence every aspect of rheumatologic care. The ACR supports transparency around the derivation of algorithms regarding reliability, variability, and the freedom from bias that impacts patient care.
We are moving toward an environment of data derived from various sources, including patient self-reports, phone apps, and wearable devices. AI can configure this data into meaningful and concise formats, potentially improving patient care and outcomes.
Algorithms looking at lab interpretation and image classification — synovial ultrasound, temporal artery ultrasound and erosions — are already available. AI programs that affect patient care must be developed to eliminate or minimize bias in decision making and must be regulated.
The interpretation of AI-provided data needs to be made in the context of each patient’s history, clinical presentation, social factors and preferences. AI interpretations should not limit access to care. We also support strict guidelines on AI program development, with attention paid to maintaining patient confidentiality and privacy.
AI will provide exciting opportunities for investigators to examine novel research avenues in rheumatic diseases. Pursuing such innovation is critical to advancing scientific breakthroughs that will be meaningful to our patients.
Although AI is a powerful tool that will have benefits, it should not be viewed as an alternative to clinical judgment provided by the rheumatologist or rheumatology professional as a part of shared decision-making with their patient. Most importantly, AI cannot replace the essential role that we in our humanity can, should and must continue to have in the care of our patients.
Healio: CAR T-cell therapy in rheumatology is similarly a hot topic. Do you believe this approach is going to revolutionize the treatment of patients with rheumatic and autoimmune conditions?
Langford: The investigation of CAR T therapy in rheumatic diseases has been an important innovation, and I look forward to the results that will emerge from ongoing studies. Although I deeply hope this will revolutionize treatment, as an investigator, I have learned to be cautious in the early stages and only reach firm conclusions once the safety and efficacy questions are answered through well-designed trials. This is exactly what I see happening with the evaluation of CAR T therapy, which makes this a very exciting scientific development to follow.
Healio: Beyond CAR T cells, what other treatments or approaches are you excited about?
Langford: The cure and prevention of rheumatic disease remain our ultimate goals. The essential interface between the lab and the bedside continues to excite me about what lies ahead in rheumatology. It is critical that we continue to train investigators and fund research to make discoveries and support our vital clinicians who are taking those discoveries forward into patient care.
Healio: Any final closing thoughts on the future of rheumatology or your tenure as ACR president?
Langford: The future of rheumatology is bright. My optimism comes from the confidence of knowing that dedicated rheumatologists and rheumatology professionals will continue to be there for their patients, applying new innovations that will improve patient outcomes and quality of life. It is an honor for me to serve the ACR as president and, more importantly, to be able to serve my fellow rheumatology specialists by supporting their objectives and priorities through the advancement of the ACR mission.
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