Your government is back to work after ending a brief government shutdown by passing a short-term continuing resolution (CR), which will keep the government running at current funding levels into February. At some point, it would be great for Congress to pass a budget (instead of a CR) and to enact bipartisan plans to increase biomedical research funds through the NIH. Several important issues complicated negotiations for the CR and the budget, including DACA, immigration and, possibly, ACA insurance market stabilization. The landscape is busy, and your advocacy team will continue to work hard to advance our profession’s top issues.
2017 in Review
Before I get into our 2018 outlook, here are a few wins and accomplishments the ACR advocacy team logged in 2017 through the work of dedicated volunteers and staff, like-minded coalition partners and relationships formed via RheumPAC (by the way, Happy RheumPAC New Year! Please make your 2018 investment today.):
- Reduced Medicare penalties by 50% for 2018;
- Delayed an insurance carrier policy to drop reimbursement for consultations;
- Cancelled the Medicare Part B Demonstration plan to cut reimbursement for medication administration in the office;
- Drafted an alternative payment model (APM) for rheumatoid arthritis. Colin Edgerton, MD, FACP, RhMSUS, chair of the ACR’s Committee on Rheumatologic Care, testified before Congress about the APM, asking for reduced risks and hurdles to qualify for the APM track (listen to his testimony, which starts at 2:35:08);
- Boosted NIH research funding by $2 billion;
- Pushed for transparency of pharmacy benefit managers (PBMs). As a result, the Senate held two hearings to publicize the dealings of PBMs and the need for transparency in the troubling drug rebate system (thanks specifically to the Alliance for Transparent & Affordable Prescriptions);
- Reversed the Medicare policy to reimburse for in-office biosimilars based on average of drugs in groups, which would have increased financial risks to practices. The new policy will reimburse drugs individually;
- Successfully called on the U.S. to restart premium processing for physicians applying for H-1B visas to work in underserved areas and boost our workforce;
- Successfully protected tax-exempt status for graduate student tuition waivers in the GOP tax bill to protect our pipeline for future medical researchers; and
- Thanks to rheumatologists and rheumatology professionals, sent more than 4,000 emails to Congress through the ACR’s Legislative Action Center (send one today); published more than 90 opinion pieces, letters to the editor and other stories; held more than 260 meetings in Congressional offices; and reviewed or monitored more than 600 pieces of legislation. You and your advocacy team are the best!
Looking to 2018, many opportunities and challenges pertain to the issues of the high cost of our medicines; growing administrative burdens; maintaining our patients’ access to care; and fostering our workforce, education and research funding. We hope to accomplish more relief for ourselves and our patients from high drug costs (see below), including a much-needed act of Congress to eliminate Part B drug costs from the MIPS payment adjustments. We’re also looking for new ways to reduce patients’ out-of-pocket expenses so they can obtain necessary treatments, for legislation to eliminate the arbitrary cap on physical therapy in Medicare and other key goals.
The Complexity of Cost in 2018
Drug prices are too high in the United States, period. Congress, President Trump, the media, insurers, businesses, patients and doctors agree. Although rheumatologists represent only about half a percent of U.S. doctors, we participate in this debate because of the relatively large costs incurred by biologics, and also the outcomes from rheumatic disease progression and disability. I can’t overstate how important it is that rheumatologists, rheumatology health professionals and our patients have a voice. We will, and you should, plan to exercise our first amendment rights to exert influence on our government to fix this price problem.
That said, it’s difficult for rheumatologists to single-handedly cut drug prices. The ACR takes strong positions, such as allowing Medicare to negotiate prices; publicizing the role PBMs play in increasing drug costs; and shepherding safe, effective biosimilars to compete in the marketplace as quickly as possible; however, current events are focusing our advocacy efforts. Right now, a few very important problems related to costs within Medicare are coming to a head and may turn the rheumatology world upside down quickly. I would like to explain two pressing issues fully:
- Biggest issue of the year: Medicare’s MIPS payment adjustments will now include Part B drug costs. This summer, groups will discover if they will have a bonus or a penalty of up to 4% in 2019. That bonus or penalty will be multiplied by the sum of the full cost of items and services, which will now include Part B drug costs, compared with prior, pre-MACRA adjustments that did not include Part B drug costs. These very high sums could magnify penalties so much that physicians stop providing Part B drugs to patients in 2019 and instead try to prescribe Part D (self-administered) drugs or, worse, they could threaten clinics’ financial viability. Meanwhile …
- MIPS performance scores will include costs for the first time in 2018. Cost will count as 10% of a provider/group score—a big jump from 0% in the first year (2017). And Medicare has communicated that the agency has not found an effective way to count costs for self-administered (Part D) drugs, but it will be able to count Part B costs. Thus, prescribing Part D drugs will not affect scores, but providing Part B drugs in the office will increase a provider’s perceived costs and, essentially, incur a penalty. Sound familiar?
The ACR’s Response
Your advocacy team has been working hard on these issues. Since early November, when it became clear that Medicare would not change the policy regarding Part B drugs in MIPS payment adjustments, the ACR has been pressuring Congress to fix the problem. In fact, I’m proud that the ACR has become a national leader on this issue. We’re hearing that a fix has bipartisan support, but it may not be as high a priority as other issues facing Congress today.
ACR President David Daikh, MD, PhD, and American Academy of Ophthalmology President Cynthia Bradford, MD, published a strong opinion piece in the influential beltway publication, The Hill, last month. We helped organize a broad coalition of physician societies and patient groups to fight this. We have also been engaged in a series of meetings with key Congressional offices, and it’s critical they hear your voice, too. Tell your elected officials to protect access to Part B therapies (currently the second advocacy campaign in the ACR’s Legislative Action Center). Patients and families of Medicare beneficiaries can send a letter. Do it now!
Medicare Rehabilitation Therapy Caps
Our Medicare patients who need physical, occupational and speech therapy face self-rationing due to the $2,010/year hard cap that was instituted on Jan. 1. Soon, patients will start hitting that cap and will not be able to receive more rehab benefits in 2018 without paying out of pocket. Luckily, with key Congressional committees supporting active legislation that permanently repeals the therapy cap, there’s momentum right now. Thirty groups, including the ACR, are campaigning to #StopTheCap by Jan. 19. Tell lawmakers: Therapy Can’t Wait! Patients and families can also send emails.
As the Trump administration works to reduce and simplify regulation across agencies, the ACR advocated for continuing the FDA’s critical scientific vigilance in developing a biosimilars marketplace. Specifically, the ACR’s wish list for the FDA regarding biosimilars includes finalizing the robust plan to require three-switch studies for biosimilars to be designated as interchangeable, and creating memorable, distinct names for biosimilars (in the form of memorable suffixes). It is quite unfortunate that despite the approval of biosimilars in the U.S., prices are being kept high and competition is being held back by dealings between pharmaceutical companies and intermediaries in the drug distribution system, like PBMs. The ACR, through ATAP, is working to fix that.
Frustrated by documentation? Confused about whether to bill a level 3 or 4? The ACR continued its work this fall to create a new set of billing codes that recognize cognitive work, instead of emphasizing procedures as the current evaluation and management (E/M) codes do. Your team, together with a coalition of cognitive specialties, met with Congressional offices and policymakers at the CMS to communicate the importance of new codes in our efforts to both incentivize physicians to go into cognitive specialties and also to more easily take part in value-based payment models, which are not set up for cognitive work. Stay tuned!
Alex Azar, the president’s nominee to lead the CMS, testified a second time in front of Congress last week. The good news: He appears to agree with our view that intermediaries, such as PBMs, incentivize higher prices, and he supports government working to reduce drug prices. The bad news: He expressed interest in allowing PBMs to work in the Part B drug space, which could increase rheumatologists’ administrative burden and potentially decrease patient access to treatment. Additionally, he stated support for Medicare demonstrations to be mandatory if needed—a significant departure from when Tom Price, MD, headed the CMS and supported doctors’ ability to opt out of demonstration projects. The Senate will likely vote on Azar’s candidacy soon, and the ACR stands ready to work with him and his team to make sure our profession and our patients are represented at the CMS.
A Final Note
As we all work on our New Year’s resolutions, remember to go out and exercise your First Amendment right to petition your government! (See what I did there?)
Angus Worthing, MD, FACP, FACR, chair, Government Affairs Committee, is a practicing rheumatologist in the Washington, D.C., metro area and clinical assistant professor of medicine at Georgetown University.