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Proposed Changes to Medicare Part B Could Limit Access To Infusion Treatments

Medicare is a federal health insurance program that pays for a variety of health care expenses. Beneficiaries of this program are generally senior citizens aged 65 or older, but younger adults with permanent disabilities may also be eligible in some cases. I don’t have any personal experience with Medicare – and seeing as I’m only 33 it will likely be quite some time until I do. But I do know that many people living with rheumatoid arthritis depend on Medicare to provide the treatment they need, which is why I have concerns about the proposed changes to Medicare Part B.

Medicare Part B is medical insurance that covers certain non-hospital medical expenses, like doctors’ office visits, blood tests, X-rays, diabetic screenings and supplies, and outpatient hospital care. The Centers for Medicare & Medicare Services (CMS) is currently considering a proposed Part B Drug Payment Model. Organizations that support patients, like the Arthritis Foundation, as well as physicians groups, like the American College of Rheumatology, are concerned about how these proposed changes may impact patients living with rheumatoid arthritis.

For starters, both organizations are concerned about the lack of stakeholder engagement in the proposal design process. This means that CMS designed the Part B Drug Payment Model without any input from the patients and providers who will be impacted by the policy. Without stakeholder engagement, policy-makers may not have a clear understanding of the unique needs of the patient populations that may be affected. For example, arthritis treatment is extremely nuanced, and a treatment that may be the most clinically effective on paper may not work for a particular patient. This means that a one-size-fits-all policy will not be effective for patients living with arthritis.

There is also concern about how the proposal might impact patient access to necessary medications and non-hospital infusion sites. If the proposed changes go into effect, there are many health care providers, such as small group and solo practitioners, who may not be able to continue offering infusions in their offices. Patients who can no longer receive infusions in their doctor’s offices will be forced to get their infusions in a hospital setting, which will drive up their out-of-pocket expenses. And, for patients in more rural areas, this would create an additional financial burden on them to travel long distances for their care. This burden is magnified even more by the fact that people with chronic diseases like rheumatoid arthritis need to receive infusions on a regular basis. If a patient cannot handle this increased financial burden, they may lose access to their infused medication – even if they were stable on that medication and even if they were not responsive to alternative medications.

The proposed Part B Drug Payment Model is also a value-based model, and it contains very little discussion of patients and patient choice. This is a problem, because ultimately any proposal that seeks to maximize health care quality must be patient-centered. Instead, this proposal could lead to patients losing access to infusions they depend on to function in daily life, even if it has taken that patient years to find a medication that works. I am very grateful that the Arthritis Foundation and the American College of Rheumatology have taken the time to send detailed letters to CMS outlining their concerns about the proposed Part B Drug Payment Model. (If you’d like to read the letters you can find the Arthritis Foundation’s letter here and the American College of Rheumatology’s letter here). For the benefit of Medicare patients living with rheumatoid arthritis, I truly hope CMS will take these concerns into consideration before making their decision.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.


  • MelbaWay
    2 years ago

    Good to read!

  • Dalia
    4 years ago

    This is very concerning! I’ve been on Medicare for about 4 years now. My copayments range from $600-$1700 a month, which I can’t afford, so I’ve been going without my infusions for almost 2 years. There aren’t any funds available from RA Med assistance and since I’m on Medicare, most pharma companies won’t offer assistance.
    Thank you for reporting on this. I hope these changes don’t come to fruition!

  • Connie Rifenburg
    4 years ago

    Zaismas may I ask if you are 65 or over? If so, you may be able to do what I did by purchasing a Medigap Plan F and just use regular Medicare A&B. It covers infusions 100% AND all your Dr. visit copays, everything! It is the best thing that has happened to me with being able to get my infusions. I had to do the same as you for the past 2 yrs.. there is hardly any $ left thru assistance for RA anymore. (my story is below) If you have any questions on how to use this feature of medicare you’re welcome to contact me via email or comment back on here and if I can help I’d be glad to.

  • Connie Rifenburg
    4 years ago

    I wasn’t aware of this change Mariah! Thank you for bringing it to my attention. This would affect me directly and I just started getting my infusions again due to turning 65 and being able to access the Medigap policy that covers in office infusions at 100%.

    I have struggled for years to find funding for for my infusions and until Apr 1st 2016, I have had to go without it because Medigap coverage is only available to those under age 65 at a rate 3 times what it costs OVER age 65!

    I have written here before that Orencia is the only infusion that has helped with my RA and for once, I can finally get my infusion every month covered by the Medigap+Medicare Part B
    coverage. This would be a terrible loss for me (and many others I’m sure)if this benefit was removed or reduced.

    This is just one more way that our government is preventing health care for every person as a “right”. Single Payer plans is a practice that every other large country in the world offers their people. America alone keeps our sick in bondage to the Insurance companies!

    Please remember this when it comes time to vote this year. Coping with a chronic disease is difficult enough without always fighting insurance companies to get the drugs and treatment you need!! It is the drug companies and the insurance companies that are deciding our healthcare and we must give that care back to our doctors!

    I will look into this further and see if there are any groups that are organizing against this change to Medicare. This, along with reducing Social Security will make it almost impossible to live with dignity into old age.

    It isn’t a privilege to have health care. And Social Security was MY money at one time. We are all REQUIRED to pay into S/S with the promise from our government that the money will be there when we retire, meanwhile, they promised to protect and invest our money so we had it to retire on. Now they are trying to take that money away because they “borrowed” from our retirement $ for wars and bank bailouts and now tell us we don’t have enough left in S/S to take care of us as we retire.

    I hope others feel as strongly about this as I do and help elect officials that will fight for the rights of the disabled and/or retired. Our Congress Members have a lifetime guaranteed retirement and health care – they don’t have to worry about Medicare and S/S taking care of them so why should they care. The Insurance companies and Drug companies line the pockets of our Representatives and we, the people, go without.

    Sorry. Guess you touched a sore spot Mariah.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Connie ~

    This is a very important issue! The U.S. Senate Finance Committee held a hearing yesterday on the Medicare Part B experiment. According to an article I just read in the NY Times, Democrats and Republicans alike expressed serious concern over how the changes would negatively impact patients. The CMS administrator at the hearing said that they intend to move forward with the proposal in some form. The final ruling could happen any time, so it’s important to continue to share our concerns with our lawmakers!


  • Carla Kienast
    4 years ago

    Mariah: I had first come aware of this when I read about the concerns for cancer patients and immediately made the mental leap to RA infusion patients. Thanks for helping raise the awareness.

  • Mariah Z. Leach moderator author
    4 years ago

    These proposed changes will certainly affect many different kinds of patients – which is why it would have been better to have stakeholders involved in developing the proposal! In some ways the burden is even intensified for RA patients, who will likely need to have their infusions indefinitely. Hopefully the efforts of the Arthritis Foundation and American College of Rheumatology will have an impact!

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