A new decade is upon us, and we have work to do. It is now January and Washington, D.C., is buzzing with impeachment hearings, drug pricing legislation volleyball and Democratic debates. Fortunately, Congress was able to pass spending packages to keep the federal government funded through September 2020. I have come to appreciate (read: accept) that changes in legislation on the state, federal and regulatory end take a very long time. Looking back at 2019 will help give us perspective for the year to come.
2019 Year in Review
A colossal thank you to Angus Worthing, MD, for his leadership during 2019. As we reflect on the wins in 2019, efforts by Angus, the Government Affairs Committee and ACR/ARP volunteers made them happen. Nearly 2,000 letters were sent to Congress, over 3 million #Act4Arthritis impressions were recorded, and 228 meetings occurred between legislators and ACR/ARP volunteers and patients.
We opened an office in Washington, D.C., to support the new ACR advocacy staff: Amanda Grimm Wiegrefe, director of regulatory affairs, and Dan Redinger, manager of advocacy and policy affairs. We are thrilled to have them join the team. Lennie Shewmaker, director of congressional affairs, has joined them in the new D.C. office. Adam Cooper, senior director of government affairs, and Joseph Cantrell, senior manager of state affairs, will continue their efforts in Atlanta and D.C. on behalf of ACR/ARP members, along with Rachel Myslinski, vice president of practice, advocacy and quality, and the rest of her team.
Add “make a RheumPAC donation” to your to-do list as a January resolution. These funds allow for nonpartisan meetings with lawmakers working on issues that impact rheumatology.
2020 Physician Fee Schedule Final Rule
The win: The Centers for Medicare & Medicaid Services (CMS) finalized the 2020 Physician Fee Schedule Final Rule, with rheumatologists seeing an estimated boost in reimbursement of up to 15% (to start in 2021). This was the second largest increase among all medical specialties.
Context: Each year, the CMS releases rules on physician reimbursement. They use recommendations from the AMA and the RVS Update Committee (RUC) to guide decisions on how to pay physicians from a single pot of money. Instead of compressing codes to a single code, the CMS valued certain CPT codes higher (those often used by subspecialties), added a complexity code that can be used by rheumatologists and modified documentation requirements to reduce administrative burdens. In this zero-sum game, other specialties were not so fortunate, with losses in surgery, radiology and physical therapy. The ACR has long advocated for and strongly supports the increase in rheumatologist reimbursement, but opposes the cuts in physical therapy.
Workforce & Loan Repayment
The win: Both the House and Senate took up a bill reauthorizing the Pediatric Subspecialty Loan Repayment Programs; H.R. 2781 passed the House in October and is now in the Senate in the Health Education Labor and Pensions (HELP) Committee, where it was discussed in December in executive session.
Context: Pediatric rheumatology fellowship slots are filled around 50% of the time, while adult rheumatology fellowship slots must turn away applicants. The above legislation attempts to address the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met.
How you can help: Send a letter to Congress encouraging the Senate to pass this important legislation.
FDA Approval for Biosimilar Interchangeability Pathway
The win: The FDA announced its approval for the interchangeability pathway for biosimilars.
Context: Biosimilars may be used as substitution of the reference product or interchangeable. The latter denotes that the drug can be used interchangeably with the reference product. No drug has yet been approved in rheumatology with interchangeable status in the U.S., but studies are ongoing. The FDA will require studies with three switches alternating between the reference product and biosimilar that report on the safety and efficacy of the drug.
Utilization Management and Reimbursement: Step Therapy, Prior Authorization & DXA Scans
For step therapy, H.R. 2279 was introduced in the spring in the House and has 124 bipartisan co-sponsors. The companion Senate bill, S. 2546, was introduced in the fall and has 12 bipartisan co-sponsors so far.
For prior authorization, H.R. 3107 was introduced in the House and has 155 bipartisan co-sponsors.
Context: Step therapy is a burden for providers and patients. This legislation requires Employee Retirement Income Security Act (ERISA) health plans to allow for reasonable overrides for physicians to be able to use certain medications. The prior authorization legislation will protect patients in Medicare Advantage plans that delay or deny access to care. It also supports reporting back to the CMS how often Medicare Advantage plans approve or deny medications and services. Funding for DXA reimbursement is at an all-time low. This legislation will set a $98 floor for DXA reimbursement.
How you can help: Send a letter to Congress showing your support.
As we look ahead in 2020, the ACR government affairs team will be tackling several issues:
- Implementing the E/M payment increases for 2021
- Tracking proposals related to drug pricing
- Advancing legislation in the areas of:
- Utilization management, including prior authorization and step therapy;
- Workforce/loan repayment; and
- NIH/DOD funding for rheumatology research.
- Tracking changes to MACRA and the new MIPS Value Pathways (MVPs)
- Addressing issues such as DXA and musculoskeletal ultrasound reimbursement
- Monitoring other legislation that could affect our members, such as congressional proposals to control surprise billing
Advocates for Arthritis
Each year I ask several patients to consider applying for the Advocates for Arthritis meeting so they can see firsthand what it is like to travel to D.C. to advocate. I let them know this meeting will give them the opportunity to speak to members of Congress and congressional aides and share their experiences.
In 2019, I was fortunate to have a physician patient join me, and he was inspired and surprised by what he learned behind the scenes in D.C. He connected the implications of legislation to both his practice of medicine and his experience as a patient. Advocates for Arthritis let him speak to legislators about his personal experience with limited access to and delays in seeing a rheumatologist, his access to biologic medications being restricted by insurance despite his position as a practicing ENT surgeon and knowledge of payer issues, his appreciation of the time spent in the room with me discussing treatment options, and his concern over the rise in price of medications. He learned how to tweet, which was amplified by his social media-savvy daughters.
These Hill visits with him illuminated what the College accomplished in 2019.
Thank you for your time, efforts, enthusiasm and perseverance. I am looking forward to an ongoing conversation about how advocacy and health policy affects you and your patients and how you can help.
Wishing you and yours a Happy New Year!
Blair Solow, MD, is chair of the ACR Government Affairs Committee and an assistant professor of medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center in Dallas.