Rheumatologists working in every practice setting face a number of challenges that can seem insurmountable. How do you cost-effectively manage administrative burdens? How do you establish an efficient and effective approach to capturing quality metrics? How do you maintain the critical elements of the care you provide, such as diagnostic musculoskeletal ultrasound and patient access to medications?
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Through the work of rheumatology advocates working for and with the ACR and through initiatives with coalition partners, such as the American Medical Association (AMA), the College has made headway with payers and on Capitol Hill to make rheumatology practice more effective for and accessible to members and the patients they serve, according to ACR Government Affairs Committee Chair Angus Worthing, MD, FACR, FACP. One example of the power ACR advocacy efforts have had recently on daily practice: the College’s success with advocating for UnitedHealthCare to continue to reimburse rheumatologists for consultations, after proposing to stop payments for these important services, Dr. Worthing shares.
Here’s a look at several key practice areas in which the ACR’s advocacy efforts have been successful and how practices are reaping the benefits.
Reducing Administrative Burdens
Administrative burdens are widespread in medical practices today on a number of fronts, including electronic medical record use, quality reporting, coding and prior authorization requirements. Reducing the administrative burdens placed on rheumatology practices has long been an ACR priority.
The ACR Committee on Rheumatologic Care (CORC) has been very active in addressing this issue, according to CORC Chair Colin Edgerton, MD, FACP, RhMSUS. “A major issue has been step edit therapy and formulary tiering requiring prior authorizations. CORC has developed a position statement advocating for meaningful and less burdensome cost-mitigation strategies. The ACR Insurance Subcommittee [ISC] communicates these positions directly to insurance companies—responding to member concerns as they arise,” Dr. Edgerton says.
For example, Dr. Edgerton shares that the ISC has been quick to respond to his practice’s concerns regarding burdensome prior authorization programs. “The ISC has scheduled calls and sent letters with significant impact, and ACR staff and volunteers are easy to contact and very responsive,” he acknowledges.
Last year, advocacy efforts by the ACR and other groups led to the passage of step therapy laws in five states and successful advances with federal step therapy legislation in Congress. The ACR, along with coalition partners including the AMA, has successfully advocated for reforms to prior authorization to streamline the process and make it more transparent, and to increase patients’ access to medicines, Dr. Worthing explains. The ACR has also helped create a consensus statement to share the rheumatology perspective on improving the prior authorization process.
Further, Dr. Worthing says the ACR is helping support state bills to reduce prior authorization requirements. There are actually several recent state-level victories on this and other key fronts affecting rheumatology administrative practices.
Creating an APM for Rheumatology
Of course, the holy grail of reducing cumbersome documentation requirements would be for rheumatologists to create their own billing codes that would then allow them to focus on pertinent aspects of patient care. This is one of the goals of the alternative payment model (APM) for patients with rheumatoid arthritis (RA), Dr. Worthing shares.
“We have created a draft model and currently are gathering practice-specific data in order to make a business case for participation in the RA APM,” notes Kwas Huston, MD, co-chair of the ACR working group that is developing the APM.
In shaping this draft RA APM, the ACR has crafted a list of billing codes that rheumatologists could use for reimbursement purposes while delivering high-quality care to people with RA. This draft APM focuses on important aspects of care, such as individual disease activity and the comorbidities that guide treatment decisions, “instead of checking boxes in a review of systems or wasting time on irrelevant quality measures,” Dr. Worthing says.
Dr. Huston explains that once the data gathering and analysis are completed, the model will likely be presented to the CMS for approval via the Physician Focused Payment Model Technical Advisory Committee.
“There is great excitement within the rheumatology community around developing alternative payments, allowing rheumatologists to truly be compensated for the important work they do,” Dr. Edgerton adds.
Pushing for Fair Biosimilar Pricing
Rheumatologists recognize biosimilars as a means to reduce costs and improve access for patients. Over the past several years, the ACR has identified several issues around biosimilars as critical to rheumatologists, including unique billing codes for biosimilars.
The previous CMS policy to reimburse equally for each biosimilar with the same bio-originator, even if one biosimilar were to cost more, would have put physician practices at financial risk for providing a more expensive biosimilar, even if it were the most medically appropriate medication for a patient. Last year, the ACR engaged in a multi-pronged advocacy campaign that included in-person meetings with policymakers to change its policy on reimbursing physicians for biosimilars given in the office setting.
After hearing from the ACR, the CMS reversed course and will now reimburse each biosimilar based on its own average sales price. “This was a victory for rheumatologists and our patients, who will have more stable access to the treatment that is best for them,” Dr. Worthing says.
“Setting unique billing codes for biosimilars was a huge step in promoting their use in rheumatology,” notes Dr. Huston. “This allows better monitoring of these products over time, as well as improved financial confidence for practices wanting to administer biosimilars.” He also says, recognizing this potential practice issue, the ACR first established a position statement on biosimilars in 2016, before the first biosimilar was approved by the FDA; the College will soon publish a white paper on the topic.
This work addressing biosimilars continues to be a focus, as outlined in the ACR’s upcoming 2018 Policy Statement, Dr. Edgerton adds.
Identifying the Importance of Diagnostic MSUS
Late last year, the CMS proposed significant payment cuts for diagnostic musculoskeletal ultrasound (MSUS) studies based on survey data that office-based specialists, instead of hospital-based specialists, were performing a majority of studies. The ACR warned the CMS that cuts would reduce utilization and training for this innovative, safe and cost-effective diagnostic technique. Within weeks, the CMS reversed course and avoided the drastic cuts, while also increasing reimbursement for more limited, diagnostic ultrasound studies, Dr. Worthing shares.
“The ACR was instrumental in working with other stakeholders to identify the importance of MSUS and communicating with CMS on the issue,” Dr. Edgerton says. “As a result, the reimbursement cuts were significantly reduced, helping protect access to this point-of-care diagnostic tool.” From his practice viewpoint, Dr. Edgerton says “the ACR work in reducing cuts to musculoskeletal ultrasound has had a profound impact in allowing my practice to continue to offer this inexpensive and critical point-of-care diagnostic tool to patients.”
Offering Support via the RISE Registry
Under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, physicians and practices who do not choose the APM for reimbursement of Medicare patients must participate in the Merit-Based Incentive Payment System (MIPS). To support members in meeting MIPS requirements, the ACR launched the Rheumatology Informatics System for Effectiveness (RISE) qualified clinical data registry, which members can access free of charge so they can submit measures for all three necessary domains while tracking and maximizing their MACRA performance.
RISE has significantly helped rheumatology practices meet MIPS requirements, according to Salahuddin Kazi, MD, vice chair of education and director of residency training in the Department of Internal Medicine’s Division of Rheumatic Diseases at the University of Texas Southwestern Medical Center in Dallas. “Our process in connecting with RISE has acted as a catalyst for us to standardize workflows to ensure that we collect the relevant data to meet quality measures. In doing so, we have already improved documentation, efficiency, and patient and provider satisfaction.”
As this practice becomes fully connected to the RISE registry, Dr. Kazi anticipates further improvements in patient care, closing gaps in care and engaging patients in their own care by having valuable dashboards to improve the delivery of effective care. “We will also be better positioned to assess and improve the MACRA-related reimbursement. The ACR has been instrumental in supporting practices by a combination of understanding the local microenvironment, and creating a nimble and agile product [the registry] to enable this transformation in care delivery,” Dr. Kazi says.
Dr. Huston agrees. “RISE has been extremely helpful in supporting and improving our reporting requirements in the MIPS program, and ACR outreach and educational programs have helped to better understand MACRA and predict its affect before the program started.” This support has helped Dr. Huston and his practice be “prepared and engaged in efforts to achieve success in the era of MACRA and value-based payment.”
From the perspective of reducing administrative burdens, Matthew Behrens, compliance manager for Rheumatology Associates in Dallas, says participation with the RISE registry “has made submitting our data for MIPS easy, especially with the support we get from the ACR. This participation has allowed us to surpass our goal for the first year of MIPS implementation.”
RISE data also help the ACR develop quality measures that rheumatologists could choose to use for future value-based reimbursement in MACRA. ACR specialists, including Ryan Larosa, are available for individualized assistance navigating MACRA.
“The ACR is only a phone call or an email away from helping. Contact someone at the ACR or visit the website,” Dr. Huston suggests. He points to an enormous breadth and depth of information on the ACR website available to members.
One area of the website Dr. Edgerton suggests members become more familiar with is the committee structure, committee progress updates and committee members. He encourages members to email him or any member of CORC with concerns or questions. He also stresses the value of volunteering with the ACR. “It is through volunteering that one best understands the power of the ACR in supporting rheumatology practices.”
Dr. Worthing agrees. He would be thrilled to provide an update on current rheumatology-oriented legislation and regulation, and the practice and advocacy resources available from the ACR to academic, state and local rheumatology society meetings. Members can contact Dr. Worthing with requests for advocacy update presentations and questions.
Read the ACR’s health policy statements and position statements to learn more about the official position the College takes on these and other critical elements of rheumatology practice.
Carina Stanton is a freelance science journalist based in Denver.