Chief Operating Officer, Bay Arthritis Institute By Andre Smith

• H.R. 879 / S. 882: The Strengthening Medicare for Patients and Providers Act — to provide annual inflationary updates to the Medicare Physician Fee Schedule, stabilizing reimbursement for smaller practices.
• S. 526 / S. 527: The PBM Transparency Act — to hold pharmacy benefit managers accountable by requiring transparency in pricing practices and limiting the manipulation of formularies that jeopardize patient access to life-changing medications.

Safeguarding the Future of Specialty Practices

At the heart of ACR’s advocacy agenda was the Medicare Provider Fee Schedule, a system that determines how healthcare providers are reimbursed for their services. Over the years, reimbursement rates have continued to decline, placing mounting financial pressure on small, independent practices.

Many rheumatologists operate these community-based practices, where personal relationships and tailored care take center stage. Bay Arthritis, a dedicated rheumatology practice, is a shining example of this. Andre Smith, one of the leading providers at Bay Arthritis, shared with lawmakers the challenges his practice faces under the current system. Andre’s story mirrors that of countless other small practices grappling with dwindling reimbursements while striving to provide patients with the highest quality, personalized care.

Andre described how, at Bay Arthritis, the focus has always been on building strong, lasting relationships with patients and addressing their unique needs. But the financial strain caused by outdated reimbursement policies jeopardizes their ability to keep the practice independent. Without immediate intervention, practices like Bay Arthritis risk being swallowed up by larger, private equity-backed systems, where the emphasis often shifts from individualized care to volume-based models.

The ACR emphasized to lawmakers that these challenges represent more than just numbers on a spreadsheet. They impact real patients and families who depend on practices like Bay Arthritis for expert, compassionate care. By pushing for fair reimbursement policies, the ACR and individuals like Andre Smith are advocating for a sustainable future where patient-focused specialty care can thrive.

Confronting the Impact of Pharmacy Benefit Managers (PBMs)

Pharmacy benefit managers (PBMs) are often behind the curtain when it comes to prescription drug prices. Acting as intermediaries between insurers, pharmacies, and drug companies, PBMs significantly influence which medications patients can access and at what cost. But there’s a serious problem.

Many PBMs operate with minimal oversight, using complex, opaque contracts to prioritize their profits over patient needs. They manipulate formularies and pricing structures, often making critical medications unaffordable or inaccessible for patients. This is particularly devastating for individuals with chronic conditions like rheumatoid arthritis, where ongoing, consistent treatment is essential.

Andre Smith has experienced these challenges firsthand while helping his patients at Bay Arthritis secure the medications they need. He described how he and his team routinely advocate on behalf of their patients, slogging through confusing PBM rules and fighting to overcome unnecessary barriers to care. According to Andre, the current system isn’t just inefficient; it’s unjust. Patients shouldn’t have to delay their treatment or settle for less effective alternatives due to corporate-driven decisions made behind closed doors.

During their discussions with lawmakers, ACR representatives, including Andre Smith, called for greater transparency and fairness in the pharmaceutical supply chain. They emphasized the importance of reforming the practices of PBMs to ensure that patients and providers can make informed decisions without being blindsided by hidden costs or inaccessible medications. These changes, they argued, are critical to restoring trust and equity in the healthcare system.

Fighting for Fairness and Transparency

Advocacy is about more than identifying problems; it’s about pursuing solutions that prioritize people over profits. The ACR’s efforts on Capitol Hill reflect this commitment. By focusing on fairness, transparency, and sustainability, they aim to provide a voice to those who too often go unheard in complex policy conversations.

This mission resonates deeply with Andre Smith, who understands the stakes all too well. For patients at Bay Arthritis, access to high-quality care and affordable medications can mean the difference between managing their condition effectively or enduring unnecessary pain and hardship. Andre’s advocacy, alongside the broader efforts of the ACR, shines a spotlight on the need for systemic reform that champions patients over corporate interests.

The fight is not just for those already struggling but for the next generation of patients and providers, ensuring that rheumatology care remains accessible and personalized. By sharing his practice’s story and engaging directly with policymakers, Andre demonstrated the human impact of these policy decisions and underscored the importance of action.

The Path Forward

The work of advocacy doesn’t end when the meetings are over. The conversations that began on Capitol Hill must now be amplified, drawing support from patients, providers, and the broader healthcare community. Building a brighter future for rheumatology care will require continuous effort—but it’s a challenge the ACR is ready to meet.

You, too, can play a part in this movement. Stay informed about the policies affecting rheumatology care, and support organizations like the ACR and community-based practices like Bay Arthritis. Providers like Andre Smith exemplify the resilience and dedication needed to push these issues forward, and they need the backing of patients and supporters to make change a reality.

By standing united, providers and patients alike can ensure that rheumatology care remains accessible, effective, and centered on the needs of individuals. And that’s a cause worth fighting for.