Joint Guideline for Treating Psoriatic Arthritis Published by the NPF and ACR

The following is a press release from the ACR dated today.

The American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) have released a joint treatment guideline for psoriatic arthritis (PsA) that provides evidence-based pharmacologic and non-pharmacologic recommendations on caring for treatment-naïve patients with active PsA and patients who continue to have active PsA despite treatment. It also includes recommendations for vaccinations, psoriatic spondylitis, predominant enthesitis, and treatment in the presence of inflammatory bowel disease, diabetes, or serious infections.

PsA is a chronic inflammatory musculoskeletal disease most commonly found in patients with psoriasis, a skin disease that causes red, scaly patches to appear on the skin. According to the NPF, more than 8 million Americans suffer from psoriasis, and it is estimated that 30 percent of them may develop PsA.

Some key recommendations from the guideline include:

  • A conditional recommendation to use treat-to-target approach for all patients with active PsA;
  • A conditional recommendation to use tumor necrosis factor inhibitor (TNFi) biologics as a first-line therapy option in patients with active PsA; and
  • A strong recommendation for smoking avoidance/cessation.

“Treat-to-target is key, because it encompasses all clinical scenarios, rather than one particular clinical situation,” said Jasvinder Singh, MD, MPH, a rheumatologist at the University of Alabama at Birmingham who served as principal investigator for the guideline project. “The available evidence suggests the irreversible joint damage, associated functional limitations, joint deformities and disability associated with PsA could possibly be avoided/delayed with optimal disease management using a targeted approach. A targeted approach can also improve pain, function and quality of life and social participation.”

The use of TNFi biologics as a first-line therapy was one of many recommendations included to help providers and patients decide between the various pharmacologic options currently available. While current GRAPPA recommendations address the use of TNFi biologics in treatment-naïve patients, this is the first guideline that specifically recommends first trying them over oral small molecule (OSM) drugs.

“The available evidence suggested that in the absence of certain conditions, many treatment-naïve patients would benefit from trying a TNFi biologic first,” said Dafna Gladman, MD, a rheumatology professor of medicine at the University of Toronto and member of the NPF Medical Board who served as a content expert on the guideline’s core team. “This doesn’t hold true once other symptoms and comorbidities are present, so OSMs can continue to be a first-line option for patients that have contraindications to TNFi treatment, as well as patients without severe PsA or psoriasis that prefer oral therapy. Providers should take into consideration all active disease domains, comorbidities, and the patient’s functional status when choosing the optimal therapy for an individual at a given point in time.”

Tofacitinib was not included within the OSM category since its benefit/risk profile differs from that of the rest of the OSMs.

The strong recommendation for smoking cessation was based on evidence linking smoking to a reduced efficacy of biologics; the benefits of smoking cessation; and the well-established link of smoking with mortality, cancers and heart and lung diseases in the general population.

The PsA guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. Due to limited data in some areas, the quality of evidence was often graded low or very low. This led to nearly all recommendations being conditional. A voting panel of rheumatologists, dermatologists, health professionals, and patients achieved consensus on the direction and the strength of the recommendations.

“Despite an expansion in the number of new therapies for the treatment of PsA, only limited studies comparing effectiveness exist to inform treatment decisions,” said Singh. “This indicates a need for head-to-head trials of various treatments and comparative effectiveness studies in both trial populations and PsA populations with comorbidities. We also need studies in patients with active PsA who are treatment-naïve, or who have tried and failed different treatment approaches. The presence of high-quality evidence will allow formulation of strong treatment recommendations.”

The complete guideline is available online on both the ACR website and NPF website.

And Now, My Liver

A few things have happened since my last health update, so I figured a new update was due.

Swallowing

While I know my rheumy put in a referral for speech pathology to help with my esophageal dysmotility, I’ve not been contacted yet. I’m sure that my swallowing issues are towards the end of their priority list, and that’s fine.

In the meantime, I’ve been relying heavily on plastic straws. The other options just do not work for me. That’s especially true when my dishwasher keeps running into rust problems. I don’t trust it to clean any kind of straw, and I don’t have the hand dexterity lately to wash them by hand. It’s an important part of why plastic straws exist – and why they shouldn’t be banned.

People who can drink without straws should, but don’t ban them. You’re losing any potential business from a wide variety of people.

GI

I’ve been keeping to my low FODMAP diet… for the most part.

Because of that, I’ve been able to recognize some other things that exacerbate my IBS. While I might not necessarily cut things like coffee completely out of my diet, I also know to expect – and prepare for – the end result. If I know I need coffee, I can premedicate with an anti-diarrheal, too, to help limit the intensity.

My follow-up is in October. I’ll likely go through with the gastroparesis study. Now that I’m not dealing with exacerbated IBS every single day, I am noticing how long it takes my body to process things… and it’s still too long.

Cardiology

My Holter monitor came back fine.

I’m floored, honestly. I have no idea how that was the case, but I also know a lot of heart issues can’t be found with that monitor. My rheumy has offered to pass me along to cardiology for a full workup.

I should take her up on it. I know I should. For some reason, though, I’m just pushing it off because, honestly, it scares the shit out of me.

Migraine

Since changing from estrogen-filled birth control pills to an IUD, my migraines has drastically decreased.

Over the last 20 days, I’ve only had 3 migraine-related issues. Two of those were full-on migraines while the other one was medicating early to stop a migraine.

MCAS

I’ve finally got a good medication routine down that stops most of the reactions I was having. Thanks to fellow MCAS patients, I’ve been able to figure out many of the things I react to. Sadly, that means limiting more dyes than I would’ve liked.

At the same time, can I live without wildberry skittles? Yes, yes I can.

Trigger Point Injections

I’ve been getting these for a while now.

I was terrified when I started, but they’ve really helped. As odd as it is to say, I’ve grown to appreciate needles in my head, neck, shoulders, and back.

I had a round of these last week and we did our fewest number of injections yet! It only took four shots to give me relief.

That’s incredibly amazing.

Because of that, we’ve been able to push off the next set from every four weeks to every six weeks… which means I get another round on Halloween!

*imagine spooky noises here*

And Now, My Liver

I stopped by the lab and got blood drawn after my injections last week. My CBC was great, but… my liver didn’t look good.

My AST was 42, when the normal range is up to 36. My ALT? 59, well above the 0-33 normal range.

While we’re not sure why this has happened, the Zyrtec I’m using to take care of my MCAS – up to 40 mg/day – can cause ‘abnormal hepatic function.’ So can my Nortriptyline, which was upped to 30 mg in June. I’m trying to only use 30 mg of Zyrtec for now and avoid using Zantac (another histamine blocker) when possible because, surprise, it can do that, too.

Rheumy has ordered another run of these labs in a month.

Time to shoot her a message about med use and a cardiology referral.

The Shipwreck and The Crumbling Temple

My body is an old ship, weathering a continuous storm. Smaller storms should feel like pebbles. Nevertheless, they pound me into rocks.

I come away with bruises from a poke,
a needle,
a bra.

Each time I feel the storm let up, to give me a break and collect my bearings, I’m made a hopeful liar.

It’s raining outside,
again.

The storms hit me like hurricanes.

I feel beaten,
sore,
exhausted.

This body feels like a ship in the middle of wrecking, throwing people overboard as I toss and turn and writhe in pain.

I do not truly ‘sleep’ anymore, not as others do. I nap for an hour here, two hours there, until pain throws me back into the waking world unprepared for the horrors I wake up to.

In the daylight, I can at least see my terrain. I know where the rocks lie, and I can avoid them. The fog, once thick enough to cloud my lungs, returns as the sun sets over the horizon. My breathing, once calm and mindful, becomes a new beast. My deepest breaths begin to resemble that of a parent birthing an heir.

I’ll have no heir. No person should need to inherent my existence, to see my soul tormented so.

As the darkness grows deeper, I can no longer avoid the rocks. The sea, gently gliding me in the daytime, becomes a monster throwing me to and fro. I no longer know which side is starboard.

I cannot sleep in my quarters, next to my lover. As the cursed vampire Dracula stole Lucy away, I too am forced to a different space. These storms, not unlike Dracula himself, chase me through the night.

Sometimes, I awaken to notice my legs running from this thief,
this vampire,
this storm.

Despite it all, my hopeful heart believes that I will make it to the morning,
the next day,
the weekend.

I try to combat the storms. I tie down all that is holy to me, anchoring them upon my bow. Leading my way through the darkness with this love guiding me seems safe. Well, safer than leading with my actual eyes. Looks, as I have learned, are deceiving in the storms.

And yet, despite my efforts, all signs point to an ending to come. There will be a time, and I’m afraid it is in the not-too-distant future when that promise of daylight does nothing. Like a thief in the night, the reaper will come for my soul. There will be no fond farewells, no happy send-offs or kisses on the forehead – just me.

We will never learn the answer to the riddles within my depths. No keys in existence can unlock the chests full of medical treasure within my hull.

Those who say our bodies are temples to be worshiped and adored have not visited this ship. They do not writhe with me in the night or awaken to new bruises and symptoms of the wreck to come. No, like Molly Brown herself, they believe they are unsinkable.

My body is no temple – or, if it is, it’s one that sits, long forgotten, until pain comes to steal its few treasures. I stand proud, alone in the wild until the booby traps snap into action.

As the thief, the raider of my tomb runs for her safety, I begin to crumble,
piece
by
piece.

In my place, I leave damage and destruction. It, too, will be forgotten. No tourists will visit my wreck and exclaim,
“O, woe is me!
I have not seen this broken land in its prime!
How did I never know such things of beauty and pain can coexist, side by side?”

No one will come to gaze upon my wreckage and wonder what else could have been done. Underwater machines will not visit my bones on the ocean floor, filming their journeys for posterities’ sake. No one will wonder what gold or charming grace is left in my depths.

No growth will come from my loss. People will not recognize the harm they’ve done by refusing my entry to calm and steady piers. They will say, “That ship was always heading for a wreck. It lasted quite a while longer than I thought it would.” Instead of mourning, people will remember only my storms that affected them.

After over a year of constant storms, amidst those caused by an ever-changing climate, the daylight stays a little longer. The fog begins to ease up and, for the first time in months, I can breathe.

For the first time in a long time, moorings appear. Instead of having to beg to be seen, someone tosses me a line.

My ship will, I know, wreck itself upon the rocks someday… but that someday is not today.

ACR Cautions Against a One-Size-Fits-All Payment Approach for Medicare

The following is a press release sent today from the American College of Rheumatology.

In comments submitted to the Centers for Medicare and Medicaid Services (CMS) regarding the 2019 Medicare Physician Fee Schedule proposed rule, the American College of Rheumatology (ACR) cautioned policymakers against implementing a proposal to reduce physician reimbursement for evaluation and management (E/M) services, arguing that doing so could severely compromise patient access to care and further exacerbate the growing rheumatology workforce shortage.

“While we applaud CMS for taking steps to reduce provider documentation and reporting burdens, we have serious concerns about the impact these cuts will have on patient access to rheumatology care,” said David Daikh, MD, PhD, President of the ACR. “A one-size-fits-all approach to reimbursement is not the way to move forward, and cuts of this magnitude will not only force physicians to spend less time with patients but could also dissuade medical students from pursuing careers in rheumatology and other specialties that treat a high volume of patients with complex needs.”

CMS’ proposal, which would create a flat payment for all E/M visits regardless of complexity, would result in significant payment cuts for treating patients with complex care needs – penalizing doctors who treat sicker patients or patients with multiple chronic conditions. These cuts also go against the recommendations of the Medicare Payment Advisory Commission (MedPAC), which earlier this year found that E/M services are undervalued relative to other physician services and recommended that reimbursements be increased rather than cut. The ACR recommends that CMS implement only the documentation relief elements of the E/M proposal, while delaying the payment changes so CMS can work closely with physicians and all stakeholders to identify alternative approaches that would ensure physicians are appropriately reimbursed according to the level of care required by each individual patient’s condition.

The ACR also expressed concern that CMS’ proposal to reduce reimbursements for procedures performed on the same day and billed as a separately identifiable E/M visit could reduce quality of care and lead to higher co-pays for patients by requiring them to return on a different day for minor procedures.

Additionally, the ACR urged CMS to:

  • Maintain the Merit-Based Incentive Payment System (MIPS) small practice bonus at 5 percent of the final score rather than move it to the quality performance category as is currently proposed.
  • Not move forward with a proposal to increase the weight of the cost performance category to 15 percent in the 2021 MIPS payment year. The ACR also urged CMS to use the best 90 days in the Cost category when calculating MIPS payment bonuses rather than the entire calendar year and exclude Part B medication costs from the cost performance category.
  • Provide physicians with more credit for participating in specialty clinical data registries under MIPS, such as the ACR RISE Registry which uses electronic health records to improve patient care, outcomes, and practice efficiency.
  • Rely on input from all stakeholders about inappropriate and excessive reduction in practice expense reimbursement for diagnostic ultrasound and other services.

“The ACR remains dedicated to ensuring that rheumatologists and rheumatology health professionals have the resources they need to provide patients with high quality care and will continue to advocate for payment reforms that reflect the way practices treat patients,” Dr. Daikh said. “We look forward to serving as a resource for CMS as it develops and implements its final 2019 Physician Fee Schedule rule.”

To view the comment letter, click here.

Posted in ACR

ACR Releases First-Ever Rheumatic Disease Report Card

The following is a press release issued by the American College of Rheumatology today.

The American College of Rheumatology (ACR) today released the Rheumatic Disease Report Card: Raising the Grade on Rheumatology Care in America, a first-of-its-kind report that evaluates just how difficult it can be to live well with a rheumatic disease in the United States.

The Rheumatic Disease Report Card provides actionable information to healthcare consumers and policymakers in all 50 states and the District of Columbia by answering the question, “How easy is it to live with a rheumatic disease in my state?” The report assigns states letter grades according to their progress in providing adequate access to rheumatology care, ensuring rheumatic disease care is affordable, and encouraging healthy lifestyle habits that ease the burden of rheumatic disease.

The average state grade was a “C,” with Maryland earning the highest grade and Oklahoma and Alabama earning the lowest grades in the report.

“This report comes at a critical time, as countless Americans living with chronic rheumatic diseases are finding it increasingly difficult to afford their prescription medications and even have access to specialized rheumatologic care,” said David Daikh, MD, PhD, President of the ACR. “This report card is an opportunity for Americans to advocate for themselves and their loved ones by raising awareness and encouraging policymakers to enact policies that improve rheumatic disease care access and affordability.”

The report findings indicate that all states have room to improve the access, affordability, and lifestyle factors associated with an individual’s ability to live well with a rheumatic disease.

A severe rheumatology workforce shortage, lack of insurance coverage and delays caused by restrictive insurer practices make it difficult for patients in many states to access rheumatic disease care. Even in states where patients can find a rheumatologist, their prescribed treatment costs are often exorbitantly expensive, as few states have taken measures to curb secretive pricing practices employed by Pharmacy Benefit Managers (PBMs) or put limits on insurers’ use of specialty tiers that implement high cost-sharing models. Furthermore, the report shows that policymakers at all levels of government can do more to make funds available for evidence-based rheumatology intervention programs like those funded by the CDC, and to support access to these programs in rural and underserved communities.

Of the 50 states and one federal district featured in the report, several states stood out as examples that others should look to as models for improving the lives of Americans with rheumatic diseases:

  • Maryland was the only state to receive an overall “A” grade due to its success in having a high concentration of rheumatologists, a low uninsured rate, laws in place to keep rheumatology care affordable, and several CDC-funded arthritis intervention programs operating in the state, including those offered by the YMCA and the National Recreation and Parks Association (NRPA).
  • Arkansas scored well in the affordability category due to state lawmakers’ recent efforts to address PBM transparency by enacting legislation that should serve as a model for future action in other states looking to address this issue.
  • Arizona received distinction for its efforts to educate primary care physicians in remote areas about rheumatic diseases so these frontline healthcare workers can better monitor and treat minor cases locally while referring more severe cases to a practicing rheumatologist. Arizona has one of the lowest concentrations of rheumatologists in the country, with only one practicing rheumatologist for every 139,000 people. Meanwhile, in Massachusetts and Maryland, there is one rheumatologist for approximately every 20,000 people – a ratio nearly seven times higher.

Rheumatic diseases are painful autoimmune and inflammatory diseases that affect a person’s joints, muscles, bones, and organs. There are more than 100 types of rheumatic diseases, including the more commonly known diseases of osteoarthritis, rheumatoid arthritis, lupus and gout.

One in four Americans are diagnosed with a rheumatic disease, and a recent academic study suggested that the number of Americans living with rheumatic disease may be as high as 91 million when taking into account reported symptoms of undiagnosed individuals. The prevalence and cost of rheumatic diseases represent a growing public health crisis. As the nation’s leading cause of disability, rheumatic diseases generate more than $140 billion in medical costs each year in the United States – surpassing the annual medical costs of cancer care.

“Rheumatic diseases can be debilitating—but they don’t have to be if a diagnosis is made without delay and appropriate treatment is started,” said Dr. Daikh. “We hope this report will help people understand that they have the power to turn the tide on this public health crisis by taking steps to raise their state’s grade on rheumatic disease care.”

The Rheumatic Disease Report Card is a project from the American College of Rheumatology (ACR) and its Simple Tasks™ public awareness campaign. Its development was guided by a national task force comprised of leading rheumatology researchers, clinicians and policy experts.

To view the Rheumatic Disease Report Card, please visit SimpleTasks.org/ReportCard.

Posted in ACR

ACR Statement Regarding the Recent CMS Guidance on Indication-Based Formulary Design

The following is a press release just issued by the American College of Rheumatology:

“While we appreciate the agency’s efforts to make prescription medications more affordable, we have serious concerns about a new CMS guidance to allow Medicare Part D plan sponsors to implement indication-based formulary designs that allow plans to select drugs for their formularies based only on the disease indications they want to use.

“These changes are a departure from current policy, which requires plans to cover each on-formulary drug for all indications that are approved by the FDA. It takes clinical decision making out of the hands of providers and puts insurance companies in control of patient treatment plans.

“Furthermore, the proposed changes will exacerbate many of the access issues patients currently face with plan usage of existing utilization management practices, such as step therapy. Unlike step therapy, which often delays effective treatments, this proposal would go even further and allow plans to remove therapies from the formulary altogether, leaving patients completely unable to access treatments that doctors and patients choose together. The ACR calls on the Trump administration not to go forward with this plan, or at a minimum to clarify the process for allowing exemptions for patients for whom a specific therapy is medically necessary. This process should be straightforward and not place an undue burden on the physician or patient in gaining access to needed medications.

“We also have concerns on what this would mean for work being done on compendia inclusion to secure off-label drug coverage if plans don’t have to cover all approved FDA-approved indications.

“We remain steadfast in our support for policies that lower costs while protecting patient access to needed therapies and look forward to continued dialogue with CMS about the proposed changes.”

Posted in ACR

On The Passing of John McCain

black background with yellow textbox and black text: On The Passing of John McCain Not Standing Still's Disease

Senator and former POW John McCain died yesterday.

Scroling through social media, I’m dismayed. I keep seeing statements from people who have forgotten McCain was not a man of the people. And, me being me, I’m upset by that. McCain was not a good person, at least politically, and we need to remember that. He did a lot of harm to communities – that’s his legacy.

I don’t have to be sad that a person who spent his life harming communities I’m a part of or I support died. This man is not some amazing person to put up on a high pedestal… unless you want to praise the systematic oppression of anyone who isn’t white, cishet, rich, conservative, American-born, and the right kind of Christian.

It’s okay to speak that truth. In fact, I would say we have a duty to do so because the GOP sure as hell isn’t going to take a break from attacking marginalized communities. They’re still scheming while tweeting out their sympathies.

McCain was horribly racist. He used racial slurs and continued doing so, though less publicly. He played a major part in selling sacred indigenous land to mining companies and golf courses. He also voted against MLK day, later saying he wished he hadn’t. Of course, McCain also elevated Sarah Palin which essentially co-founded the birther and tea party movements. That led to the administration we see today, especially with prominent birther Trump in charge.

Don’t forget that this man thought the ACA repeal effort – the one disabled people put lives on the line to stop last year – didn’t go far enough. He fought like hell to stop the ACA from being put in place. Instead of working to fix it, he campaigned on repealing it after it became law. It floors me that someone who helped with the ADA and tried to pass a patient bill of rights could also be so cruel.

On a more personal note, I didn’t have insurance coverage as a child because my mother sucks. Because SJIA is a pre-existing condition, I couldn’t get insurance on my own covering my SJIA until the ACA passed. It took a few years for me to get a job with an insurance option. I can’t imagine having had to wait until then to get care.

I could have easily died if McCain got his way, either by defeating the ACA initially or repealing it. MANY people would have. I don’t have to applaud him for making it through unspeakable things when he would’ve forced many of us into not dissimilar situations.

He could have saved disabled people. We could have stayed on home instead of being arrested. We could’ve taken care of ourselves instead of spending energy on basic human rights. All he had to do was say he would vote against it. Instead he wanted to pull a publicity stunt at the last second, telling reporters to ‘wait for the show.’

While I cried in bed, wondering what the fuck me and my disabled siblings were going to do without the ACA, McCain sat grinning on the inside like a son of a bitch. He did not care that his cavalier attitude was harming people. We were confronted with losing lifelines and he treated it like a game.

I stopped seeking diagnoses for things going on. I was afraid that whatever is going on neurologically or with my heart would get diagnosed. Without protections from the ACA, I could easily lose the ability to get any current diagnoses treated. McCain literally played a part in my poor health last year.

I won’t do about McCain’s legacy. I also won’t pretend that being a POW means he was a good person. What he chose to do when he got home and involved in politics is important. He chose to harm. He was a good republican.

I won’t speak well of someone who took pride in being a selfish asshole. If you choose to do that, you should re-examine why whitewashing history is a hobby of yours.

Rheumatology Leaders Meet with HHS Secretary Azar to Discuss Concerns with Step Therapy in Medicare Advantage Plans

The following is a press release that just came through from ACR. The below statement is from David Daikh, MD, PhD, President of the American College of Rheumatology:

“Yesterday, the American College of Rheumatology met with U.S. Department of Health and Human Services Secretary Alex Azar for a productive discussion about the rheumatology community’s concerns with a new policy that will allow Medicare Advantage plans to utilize step therapy in Medicare Part B. While we support the goal of decreasing the cost of medications, the ACR has long opposed step therapy and other utilization management techniques that undermine the clinical judgement of providers, delay access to needed treatments and put our patients’ health at unnecessary risk.”

 

“During the meeting, Secretary Azar expressed a willingness to provide clarifying language to Medicare Advantage plans that would further define the definition of ‘grandfathering.’ We hope this clarification will state that patients currently stable on their treatment will not be subjected to step therapy if they switch between Medicare Advantage plans. Such a clarification should also explain that if a patient has previously been through step therapy to arrive at an effective medication under a different health plan, they will not be subject to step therapy again when they switch plans.  Similarly, if a patient goes into remission and is able to stop taking a drug, but later needs to go back on to treatment, they will not be subject to step therapy again. We believe the aforementioned clarification would be a positive step in protecting our patients’ ability to continue with therapies that work, and urge HHS to move swiftly to provide that guidance.  We also encourage HHS to provide additional information on what this policy will mean for patients transitioning into Medicare.”

 

“We remain concerned that the provider burden will increase with this policy change but are encouraged by the Administration’s willingness to accept input and proposals on how to reduce burden. Further, we appreciate the Administration’s expressed willingness to engage with the provider community regarding the appeals process and the value of defining clinically appropriate treatment pathways as part of step therapy.  We hope that the Administration will consider making the prior authorization and appeals process in Medicare Advantage more transparent and streamlined, as this is critical for patient access.”
“While we continue to have concerns about the impact of this policy on our rheumatology patients’ ability to access timely and effective therapies, I want to thank Secretary Azar and his staff for engaging with ACR leaders and the rheumatology provider community on these issues. We look forward to continued dialogue on policy modifications that will improve patient access.”
Posted in ACR

ACR: New CMS Decision an Affront to America’s Sickest Medicare Patients

The following is a press release sent out today by the ACR.

The American College of Rheumatology (ACR) today expressed its extreme disappointment with a new Centers for Medicare and Medicaid Services (CMS) decision to allow Medicare Advantage (MA) plans to implement step therapy for Part B drugs and cross-manage Part B and D drug utilization. The policy change threatens patient access to drugs covered under Medicare Part B for the 54 million Americans living with rheumatic diseases.  This policy puts insurance companies in control of patient treatment plans – compromising medical decision making between doctors and patients prevents timely access to medications that effectively control disease.

“Put simply, this policy change is a gross affront to America’s sickest Medicare patients – individuals living with diseases like inflammatory arthritis and cancer – who depend on timely access to safe, affordable, and high-quality treatments,” said David Daikh, PhD, MD, President of the ACR. “Utilization management techniques like step therapy prevent and delay important treatments for rheumatic disease patients, which can result in irreversible joint or organ damage. At the same time that medical research is showing that early institution of effective treatment prevents such damage, CMS is instituting a policy that will makes it much more difficult for patients to get this treatment in time. We urge CMS to reconsider this policy and ensure that all Americans continue to have access to the most appropriate and effective therapy as determined by their health care team.”

Step therapy—also known as “fail first”—is a troubling practice employed by a majority of insurers that forces patients to try therapies preferred by the insurance company before being approved for the therapy their doctor prescribed—even when doctors doubt the “insurer preferred” option will be effective. Utilized by both public and private insurers, step therapy undermines the clinical judgment of healthcare providers, leads to delays in effective therapy, and puts patients’ health at unnecessary risk.

The ACR has long opposed utilization management techniques such as step therapy – in addition to others such as prior authorization, specialty tiering, and high cost-sharing – because they can prevent and delay important treatments for patients. In comments submitted to CMS last month, the ACR urged policymakers to protect patient access to Part B therapies and to instead address the issue of high treatment costs by facilitating the development of alternative payment models, expanding patient access to cost and coverage information at the time of treatment and improving FDA’s capacity and manufacturer ability to bring safe, effective biosimilars to market, which will increase competition and lower costs. The ACR also supports practices continuing to negotiate better overall drug spending through Part B than what currently occurs in Part D, as suggested by HHS’s own dashboard. Yet rather than addressing underlying causes of the high drug costs, this CMS policy seeks to reduce costs for insurers by limiting the ability of patients to receive the appropriate medications to treat their disease.

Furthermore, the ACR expressed concern over how these changes are being implemented and urged CMS to put any proposed changes through the formal rulemaking process so that patients and healthcare providers may be able to weigh in on the details of such a proposal.

“A change this seismic – one that has significant consequences for patient access to live-saving drugs – should go through the formal comment and rule-making process,” Dr. Daikh concluded.

Posted in ACR

Swallow Test and Mini-Health Update

At my rheumy appointment last week, I brought up a difficulty I’ve had with swallowing things for a while. Since my recent endoscopy didn’t find a cause, doc referred me to the hospital for a swallow test.

It was an interesting process. I had to drink a variety of liquids and a pudding laced with barium. One liquid was watery and another was the consistency of milk. The pudding was almost like marshmallow fluff. At one point, I had to eat a GF cracker folded into the fluff. I also had to swallow a barium-laced sort of alka seltzer as well as a barium tablet.

The most wildpart of this test was that they had me sit and then stand against a table – and then had me stay leaned against the table as they moved it from a vertical to horizontal position and back again! It was an absolutely wild ride, but one the tech, speech pathologist, and doc prepared me for.

Throughout all of this, obviously, an imaging system was recording how my body handled these materials while sitting, standing, and laying down. We also went from light sips to several gulps in a row for added variety.

I got the results back from that today and, surprise, after a few weeks of tests showing normal things throughout my body, this one came back abnormal! I don’t want to celebrate that but, at the same time, it feels incredibly validating since other things haven’t been found.

So, what’s wrong? I have what is called esophageal dysmotility. Essentially what that comes from is my esophagus doesn’t clear food in the normal two contractions. A third one has to happen, which means my body isn’t working as it should.

Because of that, I have a tendency to aspirate when larger amounts of fluids come into my mouth. It’s a big part of why I drink from a straw – I have to or I’ll choke. It’s not bad enough that I cough usually, but it often is.

I also have a tiny hiatal hernia. The hiatus is a small opening in the diaphragm that our food passes through to get into the stomach. For some reason, my stomach has decided to pop up into that hole. Since this can easily allow stomach acid, food, and drink back up into the throat, it’s likely a big part of why I have to stay sitting up for a while after eating unless I want my food to start coming back up. It can also play a role in shortness of breath and both chest and abdominal pain.

My rheumy has offered to give me a referral to speech pathology which also works on this fun stuff. I will be taking advantage of that for sure.

GI crud

I had a follow-up with my GI NP this week. The diagnosis that we’re running with is IBS. She’s given me a load of OTC options to consider.

I’ve already been keeping a low FODMAP diet recently. It means limiting a lot of things I enjoy eating but it’s also helped immensely. I have to avoid a lot on the list as is due to reactions I have to sugar alcohols, gluten, and more anyway.

She’s offered a referral to test for gastroparesis. To be frank, since that’s something I’ve always suspected as an issue, I may take her up on that. She doesn’t believe that it’ll yield a diagnosis at all – but she’s only seen me one other time, too.

Heart crud

In heart-related news, my echocardiogram from earlier this week came back normal – save, of course, for the tachycardia. I turned in the Holter monitor – which I had to wear for two grueling days – on Thursday. That will take a few days to read and pass results onto my rheumy, who will then pass results my way.

I’m not out of the woods here, by any means. Having a pulse of 139 at the GI follow-up isn’t a great thing at all. I’m hoping, though, that moving forward with some of these things yields good long-term results.