American Medical Association Passes ACR-Led Resolution Opposing Paying Patients to Switch Treatments

ATLANTA, Georgia, June 24 (TNSOps) -- The American College of Rheumatology issued the following news release:

The American Medical Association (AMA) House of Delegates passed a resolution developed by the American College of Rheumatology (ACR) to oppose insurance companies providing financial incentives for patients to switch from their prescribed treatment to a payer-preferred treatment during its recent June 2021 Special Meeting. The ACR drafted the resolution after learning Cigna was notifying patients on Cosentyx (secukinumab) that they could qualify for a $500 pre-paid debit card for their medical expenses if they agreed to switch to a Cigna-preferred alternative.

"We are grateful that, through the passage of this ACR-led AMA resolution (https://www.rheumatology.org/Portals/0/Files/ACR-Resolution-707-Financial-Incentives-for-Patients-to-Switch-Treatments.pdf), the larger house of medicine has agreed with us that financially incentivizing patients to switch medicines is wrong. In recent years, payers have become increasingly aggressive in the tactics they have used to direct patients to the preferred treatments on their formularies," said Chris Phillips, MD, chair of ACR's Insurance Subcommittee.

Secukinumab is a biologic medication used to treat psoriatic arthritis, moderate to severe plaque psoriasis, and ankylosing spondylitis. Ten other specialty societies signed on as cosponsors of the ACR's resolution, and it received unanimous support in its hearing prior to approval by the full House of Delegates. As a result, the AMA will now be supporting state and federal legislation to oppose the practice and will engage with state and federal regulators.

Gary Bryant, MD, chair of the ACR's delegation to the AMA House of Delegates was encouraged by the broad support across specialties and state medical associations.

"We are hopeful the AMA's new stance will increase scrutiny of these practices and encourage policy makers to pass legislation prohibiting financial payments for non-medical switching."

The ACR sent a letter to Cigna in April expressing concerns that the program used money to unethically encourage patients who were stable on an effective therapy to make decisions against the best interest of their health, especially those affected by the pandemic or in a lower socioeconomic status. The letter outlined the medical complexity of treating rheumatic diseases and potential affects non-medical switching could have on patients.

"Due to the complex nature of autoimmune diseases, two patients can have very different immune responses to the same medication in the same drug class," explained Dr. Phillips. "This can make finding the treatment that works a challenge, so the decision to choose one biologic over another requires careful clinical evaluation and consideration by a physician and patient. Factors such as an individual patient's age, gender, diagnosis, medications, specific organ manifestations, antibody status, disease severity, comorbid conditions, and ability to tolerate the route of administration strongly influence the choice of each specific biologic."

Cigna responded that they would not be making changes to the program and did not feel the payments are coercive. The ACR plans to work with the AMA to oppose legislation that would explicitly allow this practice, as well as its ongoing efforts to support lowering the overall cost of drugs while preserving patient access. More information about the ACR's 2021 policy priorities is available on the ACR website.

"We are sensitive to the need for affordable healthcare, and we share payers' desires to see cost effective treatment options for our patients. When patients cannot afford their medications, it can lead to treatment abandonment that can result in flares and irreversible damage," said Dr. Phillips. "However, a one-time payment to switch from a therapy that is working well to one the patient may not respond to unnecessarily puts the patient at risk and crosses a moral and ethical line by potentially creating a conflict between what is in the patient's financial and health interests."

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April 2, 2021

To: Scott Josephs, MD, Chief Medical Officer, Cigna, 900 Cottage Grove Road, Bloomfield, CT 06002

Dear Dr. Josephs:

On behalf of the more than 7,700 U.S. rheumatologists and rheumatology health professionals represented by the American College of Rheumatology ( I am writing to express concern about Cigna financially incentivizing rheumatic disease patients to switch treatments.

ACR members have reported that their patients are receiving letters from Cigna offering them a $500 pre-paid medical debit card if they agree to stop taking Cosentyx (secukinumab) and switch to a preferred treatment. This action jeopardizes patients' health, interferes with medical decision making and undermines the doctor patient relationship. Using money to persuade patients to make a choice against their own health is highly irresponsible, especially when so many have suffered financially due to the ongoing pandemic and may be swayed by financial incentive to make a decision contrary to their health interests. This policy raises serious ethical concerns and we urge Cigna to rescind it immediately.

Cosentyx (secukinumab) and other biologic drugs are vitally important therapeutic options for patients with rheumatic diseases. These drugs are highly effective and have the potential to reduce long-term disability; however, they are not without certain risks. All classes of biologics used in auto immune diseases may cause serious adverse events. Adverse events associated with biologics include, but are not limited to, infusion reactions, cytopenias, infections, anaphylaxis and even death. The decision to choose one biologic over another requires ca reful clinical evaluation and consideration by a physician and patient. Factors such as an individual patient's age, gender, diagnosis, medications, specific organ manifestations, antibody status, disease severity, comorbid conditions, and ability to toler ate the route of administration strongly influence the choice of each specific biologic The complex medical decision making, and subsequent risks associated with these medications, fall on the physician and the patient, so these decisions should not be curtailed by a health plan's coverage policies.

The ACR has serious ethical concerns about using money to persuade stable patients to switch treatment. Due to the highly individual characteristics outlined above, the journey to finding an effective treatment is oft en long and challenging. Incentivizing patients who are finally stable on an effective therapy to abandon treatment for non-medical reasons needlessly puts them at risk for significant long term consequences including irreversible joint damage and disability.

Patients who are switched to another treatment may experience serious disease flares, as even drugs with similar mechanisms of action have widely variable patient to patient effectiveness. Moreover, this program undermines the doctor patient relationship by possibly obliging rheumatologists to counsel patients to forgo the $500 payment in order to safeguard their health. This is particularly challenging in the current environment where the COVID 19 global pandemic has caused financial hardship for so many. To capitalize on this financial hardship as part of a strategy to force switch patients to a preferred treatment is an egregious violation of patients' welfare. This policy will disproportionately affect patients of lower socio-economic status who have less ability to refuse such a payment. For those in difficult financial circumstances, this offer of money in exchange for compromising health borders on coercion. We are also aware that your choice of drugs is not based on a truly cheaper or more effective drug, but rather those with preferred rebate status, which may change from year to year thus setting a precedent where you can routinely incentivize patients to different drugs year after year to serve your financial interests. The ACR strongly believes that all coverage policies should be based on the best interests of the patient and take into account the available peer-reviewed literature.

We realize that as biologic drug prices rise, rebate status increasingly drives formulary decisions, and we want to be very clear regarding what we regard as ethical behavior by payers in this space. While we believe all patients should have access to the treatment they and their provider feel is most appropriate, we recognize that formulary preferences for new starts may be a reality at this time. And while we strongly oppose formulary exclusions as they harm patients by obliging non-medical switching purely for profit compensating a patient for this harm might be reasonable. However, financially incentivizing a patient to ask their provider to change them from one formulary drug to another is unacceptable and morally objectionable. We will follow up with state regulators and ask them to review the legality of this policy.

We appreciate your consideration of these concerns and urge Cigna to immediately discontinue the practice of paying patients to switch treatments. We would also appreciate the opportunity to schedule a call to further discuss this policy. To schedule a call or for additional information, please contact Meredith Strozier, ACR Director of Practice Advocacy at [email protected] or (404)633 3777.

Sincerely,

Chris Phillips, MD Chair, ACR Insurance Subcommittee