To say it has been an interesting (the science—and the memes!), tumultuous (the politics) and heartbreaking (the pandemic and social injustice) year is an understatement. There have been moments of grace and inspiration that I hope have kept everyone going. As we look to 2021, we take lessons from our experiences in 2020. Washington, D.C., is buzzing with a new president, new members in the House and Senate, a new Congress (117th) and more COVID-19 legislation negotiations.
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2020 Year in Review
A colossal thank you to our Government Affairs Committee members, patient advocates, physicians and interprofessional team member advocates for taking advocacy virtual last year during a pandemic and making it a huge success. I am so grateful for the ACR staff and advocates for taking a leap of faith and jumping all in to virtual advocacy. There were 3,061 emails sent to Congress on rheumatology issues, 2,052,710 #Act4Arthritis impressions and 285 meetings with legislators and ACR/ARP volunteers and patients.
Our ACR advocacy team in D.C. (Lennie Shewmaker, JD, director of congressional affairs; Amanda Grimm Wiegrefe, MScHSRA, director of regulatory affairs; and Dan Redinger, manager of advocacy and policy affairs) and in our Atlanta office (Adam Cooper, senior director of government affairs, and Joseph Cantrell, JD, senior manager of state affairs) will continue their efforts 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 investment” to your to-do list as a new year’s resolution! These funds allow for nonpartisan meetings with lawmakers working on issues that impact rheumatology.
2021 Physician Fee Schedule Final Rule
The win: The Centers for Medicare & Medicaid Services (CMS) finalized the 2021 Physician Fee Schedule Final Rule, with rheumatologists seeing an estimated boost in reimbursement of approximately 14-15%, 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 American Medical Association’s Relative Value Scale Update Committee to guide decisions on how to pay physicians from a single pot of money. The CMS valued certain Current Procedural Terminology codes higher, including those often used by some subspecialties, 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. Given the pandemic and all practices struggling, recent COVID-19 legislation balanced the cuts some providers may see by adding $3 billion in new money, to increase Medicare Fee Schedule payments across the board by 3.75% in CY 2021.
How you can help: Watch for call-to-action alerts for sending letters to CMS to support the complex add-on code and maintain valuation of cognitive specialties.
The win: The Pediatric Subspecialty Loan Repayment Programs (PSLRP) was authorized by the CARES Act legislation; however, it is not yet funded. The Resident Physician Shortage Reduction Act (HR 1763/S. 348) made progress, with 240 cosponsors.
Context: Pediatric rheumatology fellowship slots are filled around 50% of the time, while adult rheumatology fellowship slots must turn away applicants. The final COVID package of 2020 repealed the cap on Medicare support for graduate medical education (GME) instituted by the Balanced Budget Act of 1997 and added 1,000 new Medicare-funded GME full-time equivalent residency positions, beginning in fiscal year 2023. The PSLRP legislation addresses the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met.
How you can help: Watch for calls for sending letters to Congress encouraging support of these policies.
Telehealth: Parity & Access
The win: The CMS and commercial insurance companies increased reimbursement for telehealth visits to match those of in-person visits during the public health emergency (PHE). Many states followed suit and increased telehealth reimbursement in Medicaid and some state-regulated health plans.
Context: Prior to 2020, telehealth was a novelty practiced by few providers. As in-person visits plummeted during the PHE, providers quickly learned and implemented procedures to treat patients virtually. Prior to the pandemic, reimbursements were quite low for telehealth, despite acuity and providers’ cognitive efforts. The CMS, followed by commercial insurers, increased the reimbursement for telehealth to match in-person visits for audio-visual and, later, audio-only visits. The CMS recognizes that telehealth is here to stay when this PHE is over. They have begun to add additional services to the list of covered services for telehealth for post-pandemic treatment.
How you can help: Watch for calls to action for sending letters to Congress or the administration to continue to expand telehealth flexibilities and ensure appropriate reimbursement. Also, watch for state action alerts to send letters to state legislators and executive office officials.
Utilization Management & Reimbursement: Step Therapy, Prior Authorization & DXA Scans
The wins: For step therapy, H.R. 2279 has 157 bipartisan co-sponsors and the companion Senate bill, S. 2546, has 18 bipartisan co-sponsors. For prior authorization, H.R. 3107 has 280 bipartisan co-sponsors. For DXA reimbursement, H.R. 2693 and the companion bill S. 283 have bipartisan support.
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: With the 117th Congress, all bills will need re-introduction in 2021. Send a letter to Congress showing your support. Also, watch for calls to action to send letters to state legislators if you live in a state that has not passed step therapy reform.
As we look ahead in 2021, the ACR government affairs team will be tackling several issues:
- Advocating for support for patients and providers during the remainder of the pandemic and monitoring any legislation and regulations that could affect provider and practice solvency;
- Protecting rheumatology evaluation and management payment increases;
- Engaging on policies related to telemedicine;
- Advancing legislation and regulations in the areas of:
- Prior authorization and other utilization management issues;
- Telemedicine expansion and appropriate reimbursement; and
- NIH/DOD funding for rheumatology research;
- Engaging on drug pricing proposed policies and pilot programs and defending patient access to treatment;
- Addressing issues such as DXA and musculoskeletal ultrasound reimbursement; and
- Monitoring implementation of the new requirements related to surprise billing, including the rollout of the independent dispute resolution program through which payers and providers will negotiate reimbursement.
Thank you for your time, efforts, enthusiasm and perseverance. I look forward to an ongoing conversation about how advocacy and health policy affect you and your patients and how you can help. Join us for an advocacy event, we would love to see you!
Wishing you and yours a Happy (and safe) New Year!
Blair Solow 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.