The Time Is Now for Health Care Changes

COMMENTARY

There is no question that change is happening across the country, and one place where change is desperately needed is in our health care system. Now is the time for Congress and the new administration to work together to address a broad range of issues impacting access to critical services for patients, especially those with chronic conditions.

Prioritizing these issues will help expand access to care and reduce costs for patients while bolstering the health care workforce and our entire health care system.

To start, policymakers must address pharmacy benefit manager business practices that are threatening access to vital treatments by driving up drug costs.

To protect patients, we should advance measures that include greater oversight and transparency for PBM business practices, requiring savings from drug manufacturer rebates to be passed through to patients and separating PBM compensation from the price of the drugs they place on formularies. 

These reforms will help to curb current incentives that steer patients toward higher-cost medications to line PBM’s pockets. To further help manage patient medication costs, PBMs should be encouraged to include biosimilar medications in formularies, which may lower costs for patients while preserving effective care outcomes. 

Enabling the best care outcomes for patients also means ensuring timely access to care. Patients are often forced to postpone treatment while waiting for approval, better known as prior authorization, from their insurer. These policies may have initially been intended to help control costs, but the practice has morphed into a destructive administrative nightmare for both patients and their doctors. 

Rather than bogging down routine necessary medications and care with hours of forms and follow-up, insurers — particularly those covering Medicare beneficiaries — should streamline and standardize the process. This can get patients the care they need without delay and save doctors and their staff from hours of paperwork and follow-up. 

Similarly, step therapy practices allow insurers to intervene in medical decisions between physicians and their patients. This process should be reformed. By forcing patients to “fail first” on multiple medications before finally covering the originally prescribed treatment, step therapy increases spending and delays access to the best treatment option for the patient. Eliminating copay accumulator policies and prohibiting insurers from forcing patients to switch medications for non-medical reasons would also strengthen access to treatments and reduce costs for patients.

And while, in many ways, our health care system is struggling, one recent silver lining has been the broad adoption of telemedicine.

Temporary provisions have expanded care to areas where the availability of rheumatologists may be severely limited and allowed individuals with mobility or transportation challenges easier access to care. However, these provisions are set to expire soon after a temporary extension at the end of last year. Without congressional action, providers nationwide could be forced to take a step back and leave vulnerable and rural patients with fewer options to access care.

In addition to ensuring access to care, policymakers must prioritize funding for rheumatology research. Research efforts have the potential to help curb costs associated with managing and treating arthritis and other rheumatic diseases, or even lead to earlier interventions and greater prevention. Policymakers must continue to fund efforts to spur innovations that lead to a better understanding of autoimmune and other chronic conditions.

Most importantly, policymakers cannot forget that coverage means nothing without physicians, who are the heart of our health care system. For decades, we’ve been navigating rising costs, increased administrative burden and red tape, and less and less payment from Medicare. 

To truly improve our nation’s health care system, we need broad reforms to the broken Medicare physician fee schedule. Changes like an annual inflationary update, like every other Medicare fee schedule, and repealing the cap that requires every update on spending in one is cut from another physician specialty’s reimbursements. Without such changes, the PFS comes nowhere near reflecting the true cost of providing care to Medicare beneficiaries and threatens the small businesses that are physician-owned practices. When physicians can’t afford the cost of doing business, the patients suffer. 

In the near term, legislation like H.R. 879, the Medicare Patient Access and Practice Stabilization Act of 2025, which addresses the cuts that went into effect on Jan. 1 and provides a 2% reimbursement update to Medicare providers starting April 1, would help bandage the problem if passed by Congress.

Years of sequestration cuts have chipped away at payment rates in the Medicare PFS and when combined with inflation and balanced budget requirements, are greatly weakening patient access to care.

The time is now to address this problem.

Christina Downey, M.D., is the chair of the American College of Rheumatology’s Committee on Government Affairs. She can be reached on LinkedIn.