Rheumatologists welcomed provisions in a recently enacted US federal spending package that extended some telehealth coverage and may eventually lower drug prices, but they found mixed results in terms of direct federal support for arthritis programs.

The major appropriations measure enacted on February 3 funded many federal agencies, including most health programs, for fiscal year 2026, which ends September 30. This measure thus will prevent disruptions in operations in critical parts of the federal government such as the Centers for Medicare & Medicaid Services.

“America’s doctors and their patients deserve stability — not uncertainty caused by the shutdown that jeopardizes care,” William F. Harvey, MD, MSc, president of the American College of Rheumatology (ACR), said in a press release.

As is common, Congress tacked onto this spending package some major changes for programs that fall outside the appropriations process, such as Medicare. 

Among the most substantial add-ons were 2-year extensions of Medicare telehealth payment rules. These include ones that removed some geographic requirements and expanded the scope of originating sites and practitioners eligible to provide services. 

The Congressional Budget Office (CBO) estimated a $3.8 billion cost for the extensions of some Medicare telehealth payments. While that’s a fraction of the roughly $1 trillion estimate for total annual Medicare spending, lawmakers struggle to find offsets for costs like these in omnibus spending packages. That’s made it challenging for physician and hospital groups to secure extensions of Medicare telehealth policies.

In an interview with Medscape Medical News, Harvey questioned the CBO’s approach in estimating the cost of expanding telehealth services, especially in a field like rheumatology, saying the budget office doesn’t count expected savings heavily enough.

Many people with arthritis and other illnesses treated by rheumatologists often have limited mobility, making it difficult for them to get to offices for visits, said Harvey, who is interim chief of the Division of Rheumatology at Tufts Medical Center in Boston. In addition, there’s a nationwide shortage of rheumatologists. 

“Telehealth allows us to extend our footprint to areas where there are not enough rheumatologists to care for the local population,” he said.

Expanded use of telehealth can benefit patients and taxpayers in time, with telehealth likely to reduce hospital admissions, emergency room visits, and other costs in time, advocates for telehealth argue.

“But the Congressional Budget Office doesn’t calculate those savings” in its estimates for expansions of Medicare’s telehealth policies, he said. “So, we are always advocating to Congress to understand not only the cost impact of these provisions, but also the potential benefit in reduced spending.”

In terms of fiscal 2026 appropriations, the ACR applauded the inclusion of $10 million in funding for the congressionally directed spending medical research programs (CDMRP) (also called “earmarks”) specifically for arthritis research.

“Given that arthritis is the second leading cause of medical discharge from the US Army, following only battlefield wounds, these funds will support CDMRP research aims to enhance military readiness by modifying training protocols and better preparing service members to complete their missions without incurring injuries,” Colin Edgerton, MD, a member of the ACR Board of Directors and veteran, said in a statement. “Advances in disease understanding and treatment innovations that result from this funding will not only benefit our military, but also the estimated 54.4 million American adults — including veterans — living with arthritis.”

But the ACR also said it was “deeply concerned about the drastic reduction” in funding for the CDC’s Arthritis Program, which has been cut to only $2 million. Congress earlier provided $11 million in annual funding for this program.

Changes for PBMs 

The spending package also included several provisions intended to change how pharmacy benefit managers (PBMs) operate. These include greater oversight of PBMs, with measures intended to ensure rebate savings reach patients, the ACR said. 

“This is the beginning of a set of reforms that are badly needed to help all of us better understand why the costs of medications are as high as they are,” Harvey said.

There has been significant concern for many years about what are seen as “misaligned incentives” for PBMs. If profit for these firms is pegged to the cost of medicines, PBMs benefit from higher list prices, critics of these firms say. PBM officials have long said their negotiation strategy has helped lower costs of medicines paid by consumers.

“The way in which the manufacturer’s price turns into what a patient pays is a big black box, and a large part of that black box is managed by the pharmacy benefit managers,” Harvey said. 

Provisions in the spending package are part of the initial effort to bring more transparency to this process.

“Step one is to turn the light on. Let’s see how they’re doing this,” he said.

These changes are particularly important in rheumatology, given the cost of medicines used in this field, he said. He noted that rheumatology drugs have been included in the medicines for which Medicare price negotiations began in 2023.

In an email, Madelaine (Mattie) A. Feldman, MD, a rheumatologist practicing in greater New Orleans and a past president of the Coalition of State Rheumatology Organizations (CSRO), wrote that PBMs face a “trifecta” of new regulations.

In addition to the changes in the spending bill, the Department of Labor in January proposed rules intended to compel transparency about PBM fees and compensation for many employer-sponsored health plans. 

This month, the Federal Trade Commission (FTC) said it reached a landmark settlement with one of the largest PBMs, Express Scripts, requiring the firm to “adopt fundamental changes to its business practices that increase transparency.” The FTC estimates the settlement could save consumers as much as $7 billion over 10 years, while also aiding community pharmacies.

“Rheumatology patients were among the first to experience the harmful repercussions of pharmacy benefit manager business practices,” due to the costs of their medicines, Feldman wrote. 

Like the ACR’s Harvey, Feldman welcomed the changes in PBM policy in the spending package. But both rheumatologists also were cautious in their optimism.

“PBMs have always been 5-10 years ahead of any type of regulation, and there are still enough ‘black boxes’ in the drug supply chain in which PBMs can hide profits at the expense of employers and patients,” wrote Feldman, who is currently CSRO’s vice president for advocacy and government affairs.

Kerry Dooley Young is a freelance journalist based in Washington, DC. She has covered medical research and healthcare policy for more than 20 years.