AMA Wrestles With Part B Drug Costs, Wheelchair Ramps, and Dementia Care

CHICAGO -- The American Medical Association (AMA) House of Delegates discussed whether they should push the federal government to normalize the widely varying prices of physician-administered Part B drugs, pay for wheelchair ramps to prevent costly injuries from falls, and to develop insurance coverage plans for badly needed dementia care, among other issues, during their annual meeting.

During a reference committee meeting, one resolution that prompted numerous speakers' objections was a proposal that the AMA encourage the Centers for Medicare & Medicaid Services (CMS) to restructure the price of physician-administered drugs -- often used in oncology, dermatology, and rheumatology -- so that they are on par with their counterpart biosimilar drugs that are now much less expensive.

Currently, the "buy and bill" system for these Part B drugs allows physicians to receive the cost of any given drug plus 6% of the average sales price, which may "incentivize physicians to pick the most expensive drug in a class," according to the resolution. That allows manufacturers to maintain high prices and "results in elevated Part B spending."

More competition from biosimilars could save between $2 billion and $7 billion a year.

"Under this system, physicians can increase their reimbursement by choosing the cheaper, clinically equivalent drug while also reducing cost sharing for patients," said Ashwin Varma, speaking for the Medical Student Section, which sponsored the resolution.

But former AMA president Barbara McAneny, MD, an oncologist in New Mexico, was among the first in line to object, saying the process is a lot more complicated.

"We practicing oncologists would love to be able to purchase those less expensive drugs and deliver them to patients," she said. "However, what we often find is that the insurance companies and the pharmacy benefit managers [PBMs] go to the various biosimilars and say, 'you need to give me the best discount I can get,' which the PBMs put into their own pockets and do not share with the patients or the practices that buy them. [They] then force us to choose the biosimilar which is most profitable ... For that reason, we think this should not go forward."

McAneny noted that there are "many instances where patients who get the same active compound in a biosimilar have immune reactions" to the biosimilar. "We do not want our patients to have their drugs chosen by the payers," she added.

Jason Goldman, MD, of the Florida delegation, said the issue is really about how PBMs and insurance companies practice. The desired action "will actually hurt patients and hurt access to care," because insurance companies are not going to incentivize physicians to use these medications. "They're going to just choose it for us."

Nix Employer Health Plans?

Another issue receiving lengthy discussion was whether the AMA should advocate for a health insurance system that moves away from employer-sponsored coverage. The resolution said the current system hurts patients who lose their jobs, and some 36% of employers offer only one plan, with an additional 40% offering just two.

Employer-sponsored coverage has drawbacks, such as narrow provider networks, "job lock" -- when employees feel trapped in their jobs -- and insecurity during economic downturns. Medical student Justin McGrath of New Orleans said the AMA should advocate for a national policy that allows patients to choose the plan that's best for them, even one from the marketplace.

One concern that prompted the resolution is the so-called Employer-Sponsored Health Insurance "firewall," a complicated provision in the Affordable Care Act that keeps employees with comprehensive coverage from their employer from buying a subsidized marketplace insurance plan.

But some speakers said it felt like the resolution was advocating an end to employer-sponsored coverage.

"Employer-sponsored health insurance is currently a viable form of insurance for our patients," said Stephen Wang, MD, of the Integrated Physicians Practice Section. And while it has issues, it is like any other form of insurance. "The AMA should not be in a position of trying to take away this major way to cover patients, which today does support high-quality healthcare."

Ramping Up

Concerns about injuries when patients fall from wheelchairs prompted another debate on whether the AMA should support a policy change in which Medicare Part B would pay for ramps.

According to the resolution, 90% of employed mobility device users in one study reported limits on mobility when they came upon surfaces higher than their wheeled devices. Another study found that when patients were injured by a wheelchair accident, 16% required medical intervention, often for fractures and concussions.

However, this resolution prompted concerns that spending would have to come from somewhere else, such as physician payments, because Part B spending must be cost-neutral.

Susan Hubbell, MD, of the American Academy of Physical Medicine and Rehabilitation, expressed support for ramps. "However, we're not in support of Medicare Part B covering them," she said.

Rather, she added, the AMA should help educate patients, physicians, and other healthcare providers regarding sources of funding for home modifications, such as Medicaid waivers, non-profits, and loans from the Veterans Health Administration or private non-profit groups.

Pay for Traditional Healing?

Another controversial topic -- whether traditional healing practices of American Indians and Alaska Natives should be reimbursed -- generated lengthy debate. The resolution proposed that the AMA study the use of Medicaid waivers that would reimburse for such services.

The specific types of healing practices were not defined. Luis Seija, MD, a delegate from the Minority Affairs Section, read a statement on behalf of fellow section representative Shannon Zullo, MD, who could not attend.

In her statement, Zullo said her grandfather is a practicing medicine man and that she actively practices in her tribe's traditional culture and ceremonies, but "there is no current system of accreditation to constitute a tribal healer, or what exactly would qualify as a healing ceremony to be considered reimbursable."

There is a future for reimbursable tribal healing, she noted, "but it has to be done the right way ... We could be rubber stamping a system that could be ripe for fraud and abuse."

Dementia Care

One proposal that received a lot of support was a resolution that the AMA work with CMS and other stakeholders to develop payment methods for long-term care for the rapidly growing number of people with dementia, now numbered at six million. By 2050, there will be 50 million.

Medicaid is now the main way CMS provides for long-term care, which is only available to people who have spent down their assets to below the poverty line to qualify. Long-term policies are hard to find, expensive, and often don't cover what the patient needs.

Lee Voulters, MD, a neurologist and an alternate delegate from Mississippi, called the gap in coverage for long-term care services "a sad state of affairs" for a "disenfranchised, forgotten group of patients."

Peter Hollmann, MD, a delegate from Rhode Island, said that AMA's policy on the matter of long-term care for dementia patients is good as it is. While he acknowledged that the problem is real and expensive, he said that the system now does provide long-term care for low-income patients through Medicaid in each state.

What the resolution seems to want is "wealth preservation," he said. "You're saying that if somebody dies with a million dollars, the government ought to pick up their costs for long-term care and the million dollars goes to their heirs."

"That's exactly why Medicaid is designed to [require a patient to] spend down," he added. "When you reach the end of your life and you have healthcare needs, you pay for those if you have the resources, and if you don't have the resources, then the state and federal government pay."

Correction: The original version of this story incorrectly attributed Zullo's remarks to Luis Seija, MD, who was reading a statement from Zullo.

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