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.
