Medicare Drug Savings Should Not Cost Patients Their Care

What good is a lower drug price if patients cannot find a practice that can afford to treat them? Congress can address that threat by advancing H.R. 4299.

In a congressional office last week, my heart began racing as I explained what a Medicare reimbursement change could mean for our patients.

I came prepared to discuss drug pricing. But my throat tightened as I thought about losing access to the medication that has controlled my psoriatic arthritis for eight years.

That treatment allows me to lead a rheumatology practice employing approximately 60 people, host a weekly podcast and teach medical business management. It also allows me to be present for my three sons — attending school events as they grew up and traveling to visit them now. My eldest is getting married next year.

When I talk about protecting access to treatment, I think about the lives it makes possible: the work, the family milestones and the ordinary days we want to enjoy without debilitating pain.

For someone reviewing a reimbursement spreadsheet, Cimzia is an expense. For me, it is the difference between functioning and fearing that I cannot.

That is why I joined the Coalition of State Rheumatology Organizations, or CSRO, on Capitol Hill. Beginning Jan. 1, 2028, Medicare’s negotiated drug prices will extend to physician-administered Part B medications. A policy intended to make medications more affordable could have an unintended consequence: making treatment financially unsustainable for the practices patients depend on to receive it. Congress must correct that payment structure before lower drug prices come at the expense of access to care.

The solution is already before the House: the Protecting Patient Access to Cancer and Complex Therapies Act, H.R. 4299.

It would require pharmaceutical manufacturers to fund the negotiated-price differential through rebates to Medicare while preserving practice reimbursement based on average sales price, or ASP, and patients’ lower cost-sharing. Congress should advance it before patients begin losing treatment options.

I rarely discuss my psoriatic arthritis publicly. But lawmakers need to understand what effective treatment makes possible for people with inflammatory rheumatologic conditions: the ability to work, raise families and remain independent.

My father, a physician, worked through severe pain from the same disease. I witnessed his determination. I also saw what pushing through pain demanded of him.

I tried Enbrel, Orencia, Simponi Aria and Otezla before finding the treatment that worked for me: Cimzia. When someone suggests simply switching medications, I think about the years it took to get here.

At The Hirsh Center, we estimate that changes involving Cimzia, Cosentyx and Orencia could affect approximately half our inflammatory arthritis patients. The concern extends well beyond rheumatology. The Patient Access to Community Treatment Coalition estimates that nearly 31,000 Floridians could face treatment-access challenges as Medicare’s Part B drug negotiations take effect.

CMS selected 15 medications for negotiated prices taking effect in 2028. The list includes Cimzia, Cosentyx and Orencia; Entyvio, used for Crohn’s disease and ulcerative colitis; and cancer therapies including Erleada, Kisqali, Lenvima and Verzenio. The list spans Parts B and D, whose payment systems differ. H.R. 4299 addresses the Part B reimbursement problem.

For patients receiving complex treatment, access depends on more than a prescription. It depends on a provider who can obtain the medication and sustain the services required to deliver it.

Under the “buy-and-bill” model, practices purchase medications before administering them and seeking reimbursement. They commit substantial funds to inventory and take responsibility for storage, handling and coordination.

Medicare generally pays for Part B drugs using ASP plus a statutory 6% add-on, subject to sequestration. For selected negotiated drugs, reimbursement will instead use the maximum fair price, or MFP, plus 6%. A lower benchmark means fewer add-on dollars to support the work surrounding treatment.

Although the negotiated maximum fair prices are not yet public, the CSRO materials we brought to Capitol Hill cite projected Medicare add-on payment reductions of 42% to 61%. When reimbursement makes providing these medications financially impossible, practices must stop offering them — and patients lose access to treatment.

Nor can policymakers assume hospitals will absorb patients displaced from private practices.

Some eligible hospitals obtain discounted outpatient drugs through the 340B program, giving them different purchasing economics from independent practices. But access to those discounts does not guarantee the capacity or willingness to take over these patients’ treatment.

Whatever the intent of drug negotiation, preserving the infrastructure that delivers treatment must be part of its implementation.

Put the manufacturer obligation into law

H.R. 4299 would change how the negotiated savings are delivered.

Practices would retain ASP-plus-6% reimbursement for affected Part B drugs. Manufacturers would pay Medicare rebates covering the difference between ASP-plus-6% and MFP-plus-6% payment amounts. Patients would retain coinsurance based on the lower negotiated-price calculation, subject to an additional inflation-rebate protection.

The manufacturer pays Medicare. The practice receives ASP-based reimbursement. The patient retains negotiated cost-sharing protection. It’s a triple win.

Lawmakers can act. Physicians must help them understand.

During our CSRO advocacy meetings, we spoke with staff from five congressional offices: those of Florida’s two U.S. senators and three House members. Rep. Jared Moskowitz had already signed on to H.R. 4299. In other meetings, the number of potentially affected Floridians helped make the consequences tangible.

The legislation has support from 36 Republicans and 14 Democrats, including its sponsor, Rep. Greg Murphy, R-N.C. Murphy is a practicing surgeon, co-chair of the GOP Doctors Caucus and a member of the House Ways and Means Committee, one of the committees reviewing the bill. His clinical experience and role in Medicare policy bring relevant expertise to this effort.

Bipartisan support is a beginning. Patients need legislation enacted.

I left Washington encouraged by our conversations but disappointed that it seemed fewer rheumatologists participated than in previous years. That experience strengthened my conviction that more physicians need to bring their experiences to lawmakers.

I am not a rheumatologist. I am a patient and a practice leader who cares deeply about preserving private practice care. Physicians bring clinical knowledge that I cannot replace.

“If you aren’t at the table, you’re on the menu.”

For physicians, showing up means explaining what payment changes do inside an actual practice. It means describing the patient who finally regained disease control, the resources required to continue that treatment and the consequences if the practice must stop providing it.

House members should cosponsor H.R. 4299 and press the committees of jurisdiction to advance it. Senators should champion a corresponding solution. Physicians across rheumatology, oncology, gastroenterology and other affected specialties should ask their congressional offices to support these protections — and follow up until they receive an answer.

January 2028 must not become the date Americans lose access to the medications that keep them alive, working and independent.