The national conversation around Pharmacy Benefit Managers (PBMs) often centers on drug pricing. In rheumatology practices, however, the impact goes far beyond cost. It affects operations, financial stability, physician morale, and—most importantly—patient access to care.
Administrative Barriers Are Delaying Treatment
Prior authorizations, mid-year formulary changes, and benefit shifts from medical to pharmacy coverage have become routine disruptions.
What may be framed as cost management in policy discussions translates into:
- Repeated denials and appeals
- Restarted prior authorizations when drugs shift benefits
- Staff time diverted from patient care
- Delays in medically necessary treatment
Even when payers indicate authorizations will auto-convert, practices frequently report that they do not—forcing teams to begin the process again while patients wait.
Non-Medical Switching Is Destabilizing Patients
Policies requiring patients to switch therapies for non-clinical reasons continue to create instability.
A recent example involves Blue Cross Blue Shield of Michigan, which required certain patients to move from IV-administered therapies to subcutaneous (SubQ) formulations under the pharmacy benefit.
In practice, this has led to:
- Denials for the SubQ formulation
- Denials for patients requesting to remain on IV
- Failure to auto-transfer prior authorizations
- Significant treatment delays
In one case, a patient with a documented latex allergy was denied continuation of IV therapy—even though the SubQ product contains rubber in its cap. These situations highlight how rigid coverage policies can override individualized clinical judgment and patient safety considerations.
“Underwater” Biologics Threaten Practice Sustainability
Non-medical switching to biosimilars can also create reimbursement challenges. When payment does not cover acquisition cost, practices are “underwater,” absorbing losses to continue providing care.
Independent rheumatology practices cannot sustain this model indefinitely. Misaligned reimbursement structures threaten in-office infusion services and ultimately limit patient access.
The Hidden Impact: Physician Burnout
Perhaps the most overlooked consequence is the moral distress placed on physicians.
Rheumatologists are increasingly forced to watch patients:
- Struggle to access prescribed therapies
- Face prolonged delays due to administrative barriers
- Choose between affording medication and meeting basic living expenses
This emotional toll is real. Over time, repeated denials and coverage instability contribute to burnout and may affect long-term workforce sustainability in specialty care.
PBM reform is not simply a pricing issue. For rheumatology practices, it is a care delivery issue. It is about preserving clinical autonomy. It is about sustaining specialty practices. And it is about ensuring patients receive the therapies their physicians deem medically necessary—without avoidable barriers. The impact is happening now. The conversation must reflect the realities that practices face every day.
Tags: medical office management, NORM, PBM, PBM reform, rheumatology, tips for office managers Posted by
