AHG Position Statement: “Most Favored Nation Model”

Education, Rheumatology Updates
Monday, December 14 2020

To Our Members and Partners,

Articularis Healthcare Group Inc., (AHG) stands with the rheumatology community, with the Coalition of State Rheumatology Organizations (CSRO), and with the National Organization of Rheumatology Management (NORM) in firm opposition to the CMS “Most Favored Nation Model.”

This model poses an immediate threat to patient access to treatment. The model precipitously drops payment for Medicare part B medications, but not drug prices, leaving rheumatologists unable to provide these critical treatments. The model also threatens the financial solvency of rheumatology practices, at a time when these practices are already reeling from COVID-related economic damage.

The structure and release of the model demonstrates a number of deep flaws that are unprecedented in federal procedure:

  1. A hasty release, circumventing normal federal notice-and-comment rulemaking, due for implementation January 1, 2021
  2. CMS claims that such a model is needed “…in the midst of the COVID-19 pandemic” when indeed such disruption during the pandemic is contrary to the public interest
  3. Mandatory, nation-wide participation that is significantly broader in scope than historical norms, essentially “experimenting” with the entire country’s seniors
  4. No mechanism to compel lower drug prices, leaving patients and physicians held hostage between drug manufacturers and CMS payment policy
  5. CMS has admitted that seniors will face distressing “options” to include travelling to the few facilities excluded from this experiment or to “forgo access”

The structure of the “Most Favored Nation Model” has a potential economic impact to the community practice that is NOT favorable at all:

  1. Until the end of 2020, rheumatologists will continue to operate under a payment model that is based on a minimal 4.3% (with sequestration) above the current calculations of ASP. Under the new MFN model, this will change to ASP minus 16%. This will be coupled with a flat fee of $148.73 per infusion, which overall appears to result in a severe payment deficit.
  2. Operationally, ordering drugs between the end of 2020 and 2021 is a difficulty – to date, no pricing changes have been conveyed from manufacturers that address the divergent commercial / Medicare payor mix of patients.

AHG will continue to support community rheumatology practices as they navigate the ever more complex business and regulatory environment. There is truly strength in our numbers, in our experience and in our collaborative environment.

With you all the way,

Colin C. Edgerton MD, FACP, FACR, RhMSUS
Executive Chairman, American Rheumatology Network